Provider Demographics
NPI:1942855671
Name:KESTER, DYLAN R (LSAA)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:R
Last Name:KESTER
Suffix:
Gender:M
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N GRANT ST STE A
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-5134
Mailing Address - Country:US
Mailing Address - Phone:575-388-1447
Mailing Address - Fax:575-388-1447
Practice Address - Street 1:1311 N GRANT ST STE A
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5134
Practice Address - Country:US
Practice Address - Phone:575-388-1447
Practice Address - Fax:575-388-1447
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0204901101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty