Provider Demographics
NPI:1356579866
Name:DYER, MICHELLE R
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:R
Last Name:DYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 COSGWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91732
Mailing Address - Country:US
Mailing Address - Phone:626-536-0790
Mailing Address - Fax:
Practice Address - Street 1:2130 NORTH ARROWHEAD AVENUE
Practice Address - Street 2:STE. 109
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405
Practice Address - Country:US
Practice Address - Phone:909-881-0390
Practice Address - Fax:909-881-0391
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)