MEDICARE: FOUNDATIONS DYSLEXIA & LEARNING CENTER OF COLUMBUS, LLC

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	20042503A	IN

General Provider Information

NPI Number	:	1346751401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNDATIONS DYSLEXIA & LEARNING CENTER OF COLUMBUS, LLC

Provider Business Mailing Address
First Line	:	450 JACKSON ST UNIT 1495
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-6783
Country	:	US
Telephone Number	:	812-657-4784
Fax Number	:	812-379-8068

Provider Business Practice Location Address
First Line	:	424 WASHINGTON ST STE 7
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-6790
Country	:	US
Telephone Number	:	812-657-4784
Fax Number	:	812-379-8068

Authorized Official
Title or Position	:	DIRECTOR/CLINICAL PSYCHOLOGIST
Name	:	DR. DAWN A DOUP
Credential	:	PSY.D.
Telephone Number	:	812-657-4784

Provider Enumeration Date	:	10/17/2017
Last Update Date	:	10/17/2017

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