Healthcare Provider Details

I. General information

NPI: 1164523080
Provider Name (Legal Business Name): COLLEEN DWYER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 RIVERSIDE AVE
BURLINGTON VT
05401-1601
US

IV. Provider business mailing address

81 WILLARD STREET
BURLINGTON VT
05401
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-6309
  • Fax: 802-860-4324
Mailing address:
  • Phone: 802-862-8172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0890000995
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: