MEDICARE: CARL DZYAK M.ED., BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1119655	FL

General Provider Information

NPI Number	:	1235416777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARL DZYAK M.ED., BCBA

Provider Business Mailing Address
First Line	:	6216 OLD KEENE MILL CT
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22152-2323
Country	:	US
Telephone Number	:	571-297-4308
Fax Number	:	703-992-0405

Provider Business Practice Location Address
First Line	:	6216 OLD KEENE MILL CT
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22152-2323
Country	:	US
Telephone Number	:	571-297-4308
Fax Number	:	703-992-0405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2011
Last Update Date	:	07/28/2022

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