Healthcare Provider Details

I. General information

NPI: 1033080833
Provider Name (Legal Business Name): SAM DYSART
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 S WADSWORTH BLVD STE 132
LAKEWOOD CO
80235-2106
US

IV. Provider business mailing address

3609 S WADSWORTH BLVD STE 132
LAKEWOOD CO
80235-2106
US

V. Phone/Fax

Practice location:
  • Phone: 303-902-3068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC.0022721
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: