=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457779902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARC S. DILLWORTH, PH.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2014
-----------------------------------------------------
Last Update Date | 04/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 VILLAGE GREEN PKWY
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34209-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-794-1009
-----------------------------------------------------
Fax | 941-761-5500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14566
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34280-4566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-794-1009
-----------------------------------------------------
Fax | 941-761-5500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARC SCOTT DILLWORTH
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 941-794-1009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MT 0113
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------