Provider Demographics
NPI:1750087581
Name:BRODY, DYLAN JAY (AMFT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:JAY
Last Name:BRODY
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 FREDERICK ST STE 103
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2239
Mailing Address - Country:US
Mailing Address - Phone:831-996-1222
Mailing Address - Fax:831-417-0443
Practice Address - Street 1:700 FREDERICK ST STE 103
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2239
Practice Address - Country:US
Practice Address - Phone:831-996-1222
Practice Address - Fax:831-417-0443
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137361106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist