Provider Demographics
NPI:1255653416
Name:DILLON, MARY ELLEN (MA, LCAS)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:DILLON
Suffix:
Gender:F
Credentials:MA, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 J N PEASE PL STE 103
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4560
Mailing Address - Country:US
Mailing Address - Phone:949-929-2475
Mailing Address - Fax:
Practice Address - Street 1:1909 J N PEASE PL STE 103
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4560
Practice Address - Country:US
Practice Address - Phone:949-929-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1572101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)