MEDICARE: DALLAS FLYNN RADT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	R1521850823	CA

General Provider Information

NPI Number	:	1194677658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALLAS FLYNN RADT

Provider Business Mailing Address
First Line	:	1380 VILLAGE WAY APT H103
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-4035
Country	:	US
Telephone Number	:	760-596-7917
Fax Number	:

Provider Business Practice Location Address
First Line	:	1380 VILLAGE WAY APT H103
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-4035
Country	:	US
Telephone Number	:	760-596-7917
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2026
Last Update Date	:	02/09/2026

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