Provider Demographics
NPI:1538185921
Name:DYLLER, ILENE M (PHD)
Entity type:Individual
Prefix:DR
First Name:ILENE
Middle Name:M
Last Name:DYLLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 WALNUT ST STE 801
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4719
Mailing Address - Country:US
Mailing Address - Phone:215-546-5110
Mailing Address - Fax:
Practice Address - Street 1:1315 WALNUT ST STE 801
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4719
Practice Address - Country:US
Practice Address - Phone:215-546-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015559103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA082 266Medicare ID - Type Unspecified