Provider Demographics
NPI:1457779902
Name:MARC S. DILLWORTH, PH.D.
Entity Type:Organization
Organization Name:MARC S. DILLWORTH, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:DILLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:941-794-1009
Mailing Address - Street 1:PO BOX 14566
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34280-4566
Mailing Address - Country:US
Mailing Address - Phone:941-794-1009
Mailing Address - Fax:941-761-5500
Practice Address - Street 1:501 VILLAGE GREEN PKWY
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3404
Practice Address - Country:US
Practice Address - Phone:941-794-1009
Practice Address - Fax:941-761-5500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 0113106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty