Provider Demographics
NPI:1437859683
Name:DYSERT, CANAN
Entity Type:Individual
Prefix:
First Name:CANAN
Middle Name:
Last Name:DYSERT
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 1:3815 MARQUIS PL
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-6228
Mailing Address - Country:US
Mailing Address - Phone:703-590-9874
Mailing Address - Fax:
Practice Address - Street 1:3815 MARQUIS PL
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6228
Practice Address - Country:US
Practice Address - Phone:703-590-9874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant