Healthcare Provider Details

I. General information

NPI: 1740961572
Provider Name (Legal Business Name): DYLAN DETHLEFSEN CSW, QMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DYLAN MILLER

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 3RD ST SW
WAGNER SD
57380-9675
US

IV. Provider business mailing address

513 3RD ST SW
WAGNER SD
57380-9675
US

V. Phone/Fax

Practice location:
  • Phone: 605-384-7390
  • Fax:
Mailing address:
  • Phone: 605-384-7390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6857
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: