Provider Demographics
NPI:1295001352
Name:DYER, MICHAEL KENT (BCBA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KENT
Last Name:DYER
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 FUNSTON DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-6980
Mailing Address - Country:US
Mailing Address - Phone:707-528-0723
Mailing Address - Fax:
Practice Address - Street 1:1420 FUNSTON DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-6980
Practice Address - Country:US
Practice Address - Phone:707-528-0723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-08-4738103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst