Provider Demographics
NPI:1396899506
Name:DWYER, RICHARD WILLIAM
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WILLIAM
Last Name:DWYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 E LINCOLN DR # 66
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-4121
Mailing Address - Country:US
Mailing Address - Phone:480-368-1539
Mailing Address - Fax:
Practice Address - Street 1:5635 E LINCOLN DR # 66
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-4121
Practice Address - Country:US
Practice Address - Phone:480-368-1539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ554924Medicare ID - Type UnspecifiedAHCCS NUMBER