Provider Demographics
NPI:1982071387
Name:MARTIN, DYLAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:MARTIN
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 1:2510 BECK CIR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-6765
Mailing Address - Country:US
Mailing Address - Phone:386-747-6409
Mailing Address - Fax:
Practice Address - Street 1:2510 BECK CIR
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-6765
Practice Address - Country:US
Practice Address - Phone:386-747-6409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 98321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical