Provider Demographics
NPI:1972349082
Name:GREEN, DYLAN AUSTIN
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:AUSTIN
Last Name:GREEN
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 1:102 23RD AVE SW APT A201
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7876
Mailing Address - Country:US
Mailing Address - Phone:409-781-2706
Mailing Address - Fax:
Practice Address - Street 1:325 E PIONEER
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3265
Practice Address - Country:US
Practice Address - Phone:888-910-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health