Provider Demographics
NPI:1417468406
Name:FARLEY, DESRIE DAWN (MAED, EDS)
Entity type:Individual
Prefix:MRS
First Name:DESRIE
Middle Name:DAWN
Last Name:FARLEY
Suffix:
Gender:F
Credentials:MAED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NORTH CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896
Mailing Address - Country:US
Mailing Address - Phone:618-937-2421
Mailing Address - Fax:618-932-2025
Practice Address - Street 1:508 EAST MAIN
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896
Practice Address - Country:US
Practice Address - Phone:618-932-6079
Practice Address - Fax:618-932-6836
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2543888103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool