Healthcare Provider Details

I. General information

NPI: 1881464568
Provider Name (Legal Business Name): SAMANTHA DYSON LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W62N281 WASHINGTON AVE
CEDARBURG WI
53012-2737
US

IV. Provider business mailing address

W62N281 WASHINGTON AVE
CEDARBURG WI
53012-2737
US

V. Phone/Fax

Practice location:
  • Phone: 262-623-7161
  • Fax:
Mailing address:
  • Phone: 262-623-7161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7046-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: