Provider Demographics
NPI:1396386835
Name:DYEN, ANISSA
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:DYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 MCINTOSH WAY
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4005
Mailing Address - Country:US
Mailing Address - Phone:321-439-7485
Mailing Address - Fax:
Practice Address - Street 1:324 NEWBURYPORT AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-3645
Practice Address - Country:US
Practice Address - Phone:407-796-8235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician