MEDICARE: MARILYN R DEAN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1161	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790892057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN R DEAN PSYD

Provider Business Mailing Address
First Line	:	C3800 HEARTLAND HILLS RD
Second Line	:
City	:	STRATFORD
State	:	WI
Zip	:	54484-9488
Country	:	US
Telephone Number	:	715-223-7282
Fax Number	:

Provider Business Practice Location Address
First Line	:	C3800 HEARTLAND HILLS RD
Second Line	:
City	:	STRATFORD
State	:	WI
Zip	:	54484-9488
Country	:	US
Telephone Number	:	715-223-7282
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	02/15/2012

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