MEDICARE: DYAN ELIZABETH COLVEN PSY.D.

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	103TC0700X	Clinical Psychologist	PSY14969	CA

General Provider Information

NPI Number	:	1982735635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYAN ELIZABETH COLVEN PSY.D.

Provider Business Mailing Address
First Line	:	1825 IDAHO AVE
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-3301
Country	:	US
Telephone Number	:	310-829-5030
Fax Number	:

Provider Business Practice Location Address
First Line	:	3321 EDITH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-4736
Country	:	US
Telephone Number	:	310-202-0669
Fax Number	:	310-839-4158

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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