Provider Demographics
NPI:1801466255
Name:MACK, DYLLON CADES
Entity type:Individual
Prefix:
First Name:DYLLON
Middle Name:CADES
Last Name:MACK
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 1:2292 FARADAY AVE # 100
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-7238
Mailing Address - Country:US
Mailing Address - Phone:626-390-3759
Mailing Address - Fax:855-950-0111
Practice Address - Street 1:2292 FARADAY AVE
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7238
Practice Address - Country:US
Practice Address - Phone:626-390-3759
Practice Address - Fax:855-950-0111
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician