Healthcare Provider Details

I. General information

NPI: 1720701121
Provider Name (Legal Business Name): DYLAN TYLER FAIRE PSY D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26001 REDLANDS BLVD
LOMA LINDA CA
92373-7762
US

IV. Provider business mailing address

26001 REDLANDS BLVD
LOMA LINDA CA
92373-7762
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number112806
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: