MEDICARE: STEPHANIE DYMORA

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

General Provider Information

NPI Number	:	1295194439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE DYMORA

Provider Business Mailing Address
First Line	:	PO BOX 663
Second Line	:
City	:	LAKELAND
State	:	MI
Zip	:	48143-0663
Country	:	US
Telephone Number	:	810-599-2129
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 SAINT ANDREWS RD
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48638-5977
Country	:	US
Telephone Number	:	989-401-9020
Fax Number	:

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

Provider Enumeration Date	:	02/16/2016
Last Update Date	:	06/08/2023

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