Provider Demographics
NPI:1407538085
Name:YORK, DUSTIN CLAY
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:CLAY
Last Name:YORK
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 1:1702 JIMMY ST
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-1221
Mailing Address - Country:US
Mailing Address - Phone:229-474-5144
Mailing Address - Fax:
Practice Address - Street 1:1702 JIMMY ST
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-1221
Practice Address - Country:US
Practice Address - Phone:229-474-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-286652106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician