MEDICARE: SAM DYSART

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	101YP2500X	Professional Counselor	LPC.0022721	CO

General Provider Information

NPI Number	:	1033080833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAM DYSART

Provider Business Mailing Address
First Line	:	12295 ORACLE BLVD STE 340
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3902
Country	:	US
Telephone Number	:	719-203-1856
Fax Number	:

Provider Business Practice Location Address
First Line	:	12295 ORACLE BLVD STE 340
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3902
Country	:	US
Telephone Number	:	719-203-1856
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2025
Last Update Date	:	01/22/2026

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Directions to “ SAM DYSART ” Practice Location

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