Provider Demographics
NPI:1831750793
Name:DOMINGOS, DYLAN COLE
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:COLE
Last Name:DOMINGOS
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 1:5804 143RD ST SW UNIT A
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-3724
Mailing Address - Country:US
Mailing Address - Phone:559-478-3996
Mailing Address - Fax:
Practice Address - Street 1:5804 143RD ST SW UNIT A
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-3724
Practice Address - Country:US
Practice Address - Phone:559-478-3996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician