Provider Demographics
NPI:1952153405
Name:SPOOR, DYLAN O'NEIL (SUDPT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:O'NEIL
Last Name:SPOOR
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 TYEE DR SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7356
Mailing Address - Country:US
Mailing Address - Phone:360-464-6700
Mailing Address - Fax:
Practice Address - Street 1:1016 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-2631
Practice Address - Country:US
Practice Address - Phone:360-942-2474
Practice Address - Fax:360-533-9750
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61518322101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)