Provider Demographics
NPI:1760638498
Name:MARIAH, DYLAN S (RN, LMHC)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:S
Last Name:MARIAH
Suffix:
Gender:F
Credentials:RN, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 STARLIGHT CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9330
Mailing Address - Country:US
Mailing Address - Phone:585-200-4646
Mailing Address - Fax:
Practice Address - Street 1:20 OFFICE PARK WAY STE 107
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534
Practice Address - Country:US
Practice Address - Phone:585-200-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2020-04-10
Deactivation Date:2014-01-02
Deactivation Code:
Reactivation Date:2018-12-28
Provider Licenses
StateLicense IDTaxonomies
NY002604101YP2500X
NY543015-1163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional