Healthcare Provider Details

I. General information

NPI: 1740788835
Provider Name (Legal Business Name): DYLAN NIKKEL RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14844 W 107TH ST
LENEXA KS
66215-4002
US

IV. Provider business mailing address

14844 W 107TH ST
LENEXA KS
66215-4002
US

V. Phone/Fax

Practice location:
  • Phone: 720-319-7614
  • Fax: 720-319-7614
Mailing address:
  • Phone: 720-319-7614
  • Fax: 720-319-7614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number16-22492
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: