Provider Demographics
NPI:1699436055
Name:DICKINSON, DARIN DRAKE
Entity type:Individual
Prefix:
First Name:DARIN
Middle Name:DRAKE
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 KINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-2521
Mailing Address - Country:US
Mailing Address - Phone:909-921-2476
Mailing Address - Fax:
Practice Address - Street 1:13200 CROSSROADS PKWY N BLDG 300
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3459
Practice Address - Country:US
Practice Address - Phone:562-841-1491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2301735106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician