Provider Demographics
NPI:1982364113
Name:DILLEY, RICHARD LEROY JR (LMT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LEROY
Last Name:DILLEY
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 SAINT PAUL AVE APT A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5466
Mailing Address - Country:US
Mailing Address - Phone:608-235-2227
Mailing Address - Fax:
Practice Address - Street 1:345 W WASHINGTON AVE STE 404
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3007
Practice Address - Country:US
Practice Address - Phone:608-235-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15089-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist