Healthcare Provider Details

I. General information

NPI: 1841699220
Provider Name (Legal Business Name): DYLAN MICHAEL PANUSKA PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3329 75TH ST FL 2
WOODRIDGE IL
60517-2700
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 630-964-9400
  • Fax: 630-964-9375
Mailing address:
  • Phone: 847-570-2040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008788
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: