Provider Demographics
NPI:1063425064
Name:DALRYMPLE, DAVID JACK (DMIN, LCPC, NCPSYA)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JACK
Last Name:DALRYMPLE
Suffix:
Gender:M
Credentials:DMIN, LCPC, NCPSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1370
Mailing Address - Country:US
Mailing Address - Phone:815-397-7729
Mailing Address - Fax:815-397-7729
Practice Address - Street 1:2007 VALLEY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1370
Practice Address - Country:US
Practice Address - Phone:815-397-7729
Practice Address - Fax:815-397-7729
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10108005OtherBC/BS
ILMHS482493OtherVALUEOPTIONS