MEDICARE: MR. DYLAN COOPER AMFT

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	106H00000X	Marriage & Family Therapist	133594	CA
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1851080014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DYLAN COOPER AMFT

Provider Business Mailing Address
First Line	:	6800 INDIANA AVE STE 260
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-4287
Country	:	US
Telephone Number	:	951-782-0040
Fax Number	:	951-782-2010

Provider Business Practice Location Address
First Line	:	6800 INDIANA AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-4269
Country	:	US
Telephone Number	:	909-262-6431
Fax Number	:

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

Provider Enumeration Date	:	05/03/2023
Last Update Date	:	10/27/2023

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