Healthcare Provider Details

I. General information

NPI: 1144757691
Provider Name (Legal Business Name): DAWN WYMAN LICSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 05/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 EXECUTIVE PARK DR STE 212
BEDFORD NH
03110-6975
US

IV. Provider business mailing address

PO BOX 4275
MANCHESTER NH
03108-4275
US

V. Phone/Fax

Practice location:
  • Phone: 603-440-4519
  • Fax: 603-232-3079
Mailing address:
  • Phone: 603-440-4519
  • Fax: 603-232-3079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEE DIETER
Title or Position: BILLING MANAGER
Credential:
Phone: 603-714-0870