Provider Demographics
NPI:1114464260
Name:OROSCO, DYLAN
Entity Type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:
Last Name:OROSCO
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 1:1905 NANCY LOPEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:RIO COMMUNITIES
Mailing Address - State:NM
Mailing Address - Zip Code:87002-5954
Mailing Address - Country:US
Mailing Address - Phone:505-350-4595
Mailing Address - Fax:
Practice Address - Street 1:1709 MOON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3935
Practice Address - Country:US
Practice Address - Phone:505-321-5254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NM101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator