1003136672 NPI number — MR. BRETT TYLER DILLARD B.S.W.

Table of content: MR. BRETT TYLER DILLARD B.S.W. (NPI 1003136672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003136672 NPI number — MR. BRETT TYLER DILLARD B.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DILLARD
Provider First Name:
BRETT
Provider Middle Name:
TYLER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
B.S.W.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003136672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 LAFAYETTE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTOTOC
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38863-2837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-509-9300
Provider Business Mailing Address Fax Number:
662-509-6698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 LAFAYETTE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONTOTOC
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38863-2837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-509-6759
Provider Business Practice Location Address Fax Number:
662-509-6761
Provider Enumeration Date:
06/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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