=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306601679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYLAN AVERY FARNSWORTH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2024
-----------------------------------------------------
Last Update Date | 02/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 913 E ARLINGTON BLVD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-5864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-999-8559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1507 ROUGH RIDER LN
-----------------------------------------------------
City | PARKTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28371-7719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-494-1296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------