Healthcare Provider Details

I. General information

NPI: 1548572183
Provider Name (Legal Business Name): STEVEN O DYSON LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6337 S WOODLAWN AVE
CHICAGO IL
60637-3707
US

IV. Provider business mailing address

333 S STATE ST
CHICAGO IL
60604-3900
US

V. Phone/Fax

Practice location:
  • Phone: 312-474-0059
  • Fax: 312-747-0088
Mailing address:
  • Phone: 312-747-0059
  • Fax: 312-747-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number366005820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: