Healthcare Provider Details

I. General information

NPI: 1740855808
Provider Name (Legal Business Name): DYLAN THOMAS HONNOLD MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 07/25/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26812 118TH AVE E
GRAHAM WA
98338
US

IV. Provider business mailing address

PO BOX 862
GRAHAM WA
98338-0862
US

V. Phone/Fax

Practice location:
  • Phone: 360-808-3263
  • Fax: 888-977-1564
Mailing address:
  • Phone: 253-600-9224
  • Fax: 888-977-1564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMG61293010
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: