Provider Demographics
NPI:1932245701
Name:DILLON, ILENE L (MSW)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:L
Last Name:DILLON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 OAK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-3506
Mailing Address - Country:US
Mailing Address - Phone:415-454-5363
Mailing Address - Fax:510-223-4171
Practice Address - Street 1:905 SIR FRANCIS DRAKE BLVD STE D
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1589
Practice Address - Country:US
Practice Address - Phone:415-454-5363
Practice Address - Fax:510-223-4171
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 70351041C0700X
CAMFC 5747106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ70577ZOtherBLUE SHIELD
CALCS 7035OtherCLINICAL SOCIAL WK LIC
CAMFC 5747OtherMFT LICENSE NUMBER