Provider Demographics
NPI:1710719562
Name:COLE, DYLAN FORREST (YPSS)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:FORREST
Last Name:COLE
Suffix:
Gender:M
Credentials:YPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2891
Mailing Address - Country:US
Mailing Address - Phone:503-546-6377
Mailing Address - Fax:503-546-9397
Practice Address - Street 1:6200 SE KING RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-2891
Practice Address - Country:US
Practice Address - Phone:503-546-6377
Practice Address - Fax:503-546-9397
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR112021175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist