Provider Demographics
NPI:1689331332
Name:DYER, COLBY J
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:J
Last Name:DYER
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 1:1641 RAT PACK AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-9380
Mailing Address - Country:US
Mailing Address - Phone:702-682-6472
Mailing Address - Fax:
Practice Address - Street 1:8685 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2839
Practice Address - Country:US
Practice Address - Phone:702-754-0807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
NV10320-M1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner