MEDICARE: J. LEWIS MYLAR, PHD, PC

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	103TC0700X	Clinical Psychologist	308	CO

General Provider Information

NPI Number	:	1326231770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. LEWIS MYLAR, PHD, PC

Provider Business Mailing Address
First Line	:	524 N TEJON ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-4926
Country	:	US
Telephone Number	:	719-633-2008
Fax Number	:

Provider Business Practice Location Address
First Line	:	524 N TEJON ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-4926
Country	:	US
Telephone Number	:	719-633-2008
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	J. LEWIS MYLAR
Credential	:	PHD, P.C.
Telephone Number	:	719-633-2008

Provider Enumeration Date	:	08/20/2007
Last Update Date	:	08/20/2007

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