Provider Demographics
NPI:1841336757
Name:DILLAVOU, DALE E (PHD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:E
Last Name:DILLAVOU
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NORTH HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-3406
Mailing Address - Country:US
Mailing Address - Phone:781-862-2576
Mailing Address - Fax:
Practice Address - Street 1:545 CONCORD AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-499-9977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3613103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3310OtherAMERICAN ACADEMY OF HEALT
34261OtherNATL REG OF HEALTH CARE P