Provider Demographics
NPI:1740855808
Name:HONNOLD, DYLAN THOMAS (MA)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:THOMAS
Last Name:HONNOLD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 862
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-0862
Mailing Address - Country:US
Mailing Address - Phone:253-600-9224
Mailing Address - Fax:888-977-1564
Practice Address - Street 1:26812 118TH AVE E
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338
Practice Address - Country:US
Practice Address - Phone:360-808-3263
Practice Address - Fax:888-977-1564
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMG61293010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program