Provider Demographics
NPI:1477012342
Name:DWYER, MICHAEL BENJAMIN (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:DWYER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 MEIGS ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2429
Mailing Address - Country:US
Mailing Address - Phone:706-338-2600
Mailing Address - Fax:
Practice Address - Street 1:1551 JENNINGS MILL RD UNIT 1700B
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7266
Practice Address - Country:US
Practice Address - Phone:404-450-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW008279104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty