Healthcare Provider Details

I. General information

NPI: 1790035574
Provider Name (Legal Business Name): DYLAN RAY ATHENOUR MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUIR RD
MARTINEZ CA
94553-4668
US

IV. Provider business mailing address

150 MUIR RD
MARTINEZ CA
94553-4668
US

V. Phone/Fax

Practice location:
  • Phone: 925-372-2569
  • Fax:
Mailing address:
  • Phone: 925-372-2569
  • Fax: 925-372-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY28710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: