Provider Demographics
NPI:1043837230
Name:ANDERSON, DYLAN TEDVON
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:TEDVON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 BUTTERFIELD RD APT 103
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-4310
Mailing Address - Country:US
Mailing Address - Phone:918-934-6217
Mailing Address - Fax:
Practice Address - Street 1:255 E LAKE ST STE AND106
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1287
Practice Address - Country:US
Practice Address - Phone:815-295-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health