Provider Demographics
NPI:1972140655
Name:HART, DUSTIN RYAN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:RYAN
Last Name:HART
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 1:2236 BEMISS RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1942
Mailing Address - Country:US
Mailing Address - Phone:229-474-9800
Mailing Address - Fax:
Practice Address - Street 1:2236 BEMISS RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1942
Practice Address - Country:US
Practice Address - Phone:229-474-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-18-62485106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician