Provider Demographics
NPI:1730659004
Name:DILDINE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DILDINE
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 1:505 VILLA AVE APT 166
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0873
Mailing Address - Country:US
Mailing Address - Phone:559-908-0020
Mailing Address - Fax:
Practice Address - Street 1:20 N DEWITT AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0311
Practice Address - Country:US
Practice Address - Phone:559-575-8172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37-1858777103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst