Provider Demographics
NPI:1245338599
Name:MARILYN M DYRE PHD LCSW PC
Entity type:Organization
Organization Name:MARILYN M DYRE PHD LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DYRE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:815-455-1884
Mailing Address - Street 1:333 COMMERCE DR
Mailing Address - Street 2:STE 150
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-455-1884
Mailing Address - Fax:815-455-1896
Practice Address - Street 1:333 COMMERCE DR
Practice Address - Street 2:STE 150
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-455-1884
Practice Address - Fax:815-455-1896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KZ6652Medicare ID - Type Unspecified
213347Medicare ID - Type Unspecified