Provider Demographics
NPI:1366650467
Name:DYER, THERESA M (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:DYER
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 WOODHULL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-3513
Mailing Address - Country:US
Mailing Address - Phone:631-553-5212
Mailing Address - Fax:631-939-2096
Practice Address - Street 1:177 WOODHULL AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3513
Practice Address - Country:US
Practice Address - Phone:631-553-5212
Practice Address - Fax:631-939-2096
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1041S0200X
NYR045529-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool