Provider Demographics
NPI:1639847262
Name:MITCHELL, DYLAN EDWARD
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:EDWARD
Last Name:MITCHELL
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 1:1255 ELMWOOD DR APT 17
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1220
Mailing Address - Country:US
Mailing Address - Phone:708-910-8483
Mailing Address - Fax:
Practice Address - Street 1:3940 RANCHERO DR STE 100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3900
Practice Address - Country:US
Practice Address - Phone:734-929-4596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician