Provider Demographics
NPI:1518796861
Name:CERTAIN, DAKOTA RAY
Entity type:Individual
Prefix:
First Name:DAKOTA
Middle Name:RAY
Last Name:CERTAIN
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 1:10145 PRAIRIE FAWN DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-3414
Mailing Address - Country:US
Mailing Address - Phone:520-496-7117
Mailing Address - Fax:
Practice Address - Street 1:9685 VIA EXCELENCIA STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-7500
Practice Address - Country:US
Practice Address - Phone:619-369-5059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-23-291945106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty