Provider Demographics
NPI:1588036693
Name:DWYER, JOHN GORDIAN (LMHC,, CAP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GORDIAN
Last Name:DWYER
Suffix:
Gender:M
Credentials:LMHC,, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4350
Mailing Address - Country:US
Mailing Address - Phone:813-272-2244
Mailing Address - Fax:813-272-3766
Practice Address - Street 1:3309 W WATERS AVE STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2766
Practice Address - Country:US
Practice Address - Phone:813-898-0014
Practice Address - Fax:813-898-0015
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1729104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017535600Medicaid