Provider Demographics
NPI:1932615515
Name:RUTTER, DYLAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:RUTTER
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 1:7175 COLUMBIA GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-2534
Mailing Address - Country:US
Mailing Address - Phone:888-394-5977
Mailing Address - Fax:
Practice Address - Street 1:7175 COLUMBIA GATEWAY DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2536
Practice Address - Country:US
Practice Address - Phone:888-344-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA562103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst