Provider Demographics
NPI:1487470886
Name:DWYER, STEPHEN RANDALL
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:RANDALL
Last Name:DWYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 AXLINE RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-1574
Mailing Address - Country:US
Mailing Address - Phone:217-638-8655
Mailing Address - Fax:
Practice Address - Street 1:70 AXLINE RD
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-1574
Practice Address - Country:US
Practice Address - Phone:217-638-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0282801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical