MEDICARE: DR. LESLIE DWYER PSY.D.

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	103TC1900X	Counseling Psychologist	LPC #257	CO

General Provider Information

NPI Number	:	1043629660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE DWYER PSY.D.

Provider Business Mailing Address
First Line	:	425 W MULBERRY ST STE 210
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-2864
Country	:	US
Telephone Number	:	970-224-5226
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 W MULBERRY ST STE 210
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-2864
Country	:	US
Telephone Number	:	970-224-5226
Fax Number	:

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

Provider Enumeration Date	:	08/07/2014
Last Update Date	:	08/07/2014

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