Healthcare Provider Details

I. General information

NPI: 1134842966
Provider Name (Legal Business Name): DYLAN WREN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5081 BEATLINE RD
LONG BEACH MS
39560-3814
US

IV. Provider business mailing address

5081 BEATLINE RD
LONG BEACH MS
39560-3814
US

V. Phone/Fax

Practice location:
  • Phone: 601-439-6265
  • Fax:
Mailing address:
  • Phone: 228-806-7182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2425
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2425
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: