Provider Demographics
NPI:1275231920
Name:SUMMERS, DYLAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:SUMMERS
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 1:14 RACE ST
Mailing Address - Street 2:
Mailing Address - City:DRY RIDGE
Mailing Address - State:KY
Mailing Address - Zip Code:41035-9779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3580 HARGRAVE CT
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:KY
Practice Address - Zip Code:41048-6900
Practice Address - Country:US
Practice Address - Phone:859-317-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22-215417106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician