Healthcare Provider Details

I. General information

NPI: 1619641057
Provider Name (Legal Business Name): ALYSSA DYBDAHL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2021
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 CHICAGO AVE STE 203
RIVERSIDE CA
92507-2209
US

IV. Provider business mailing address

18726 S WESTERN AVE
GARDENA CA
90248-3813
US

V. Phone/Fax

Practice location:
  • Phone: 951-357-6926
  • Fax: 855-568-2494
Mailing address:
  • Phone: 310-856-0800
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: