Provider Demographics
NPI:1881717288
Name:DYSON, VIDA BERNADETTE (PHD)
Entity type:Individual
Prefix:DR
First Name:VIDA
Middle Name:BERNADETTE
Last Name:DYSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9747 S OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1720
Mailing Address - Country:US
Mailing Address - Phone:773-429-1847
Mailing Address - Fax:773-881-9535
Practice Address - Street 1:9730 S WESTERN AVE
Practice Address - Street 2:SUITE 627
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2814
Practice Address - Country:US
Practice Address - Phone:708-261-8922
Practice Address - Fax:773-881-9535
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001635116OtherBLUE CROSS BLUE SHIELD