Provider Demographics
NPI:1902954589
Name:DAWSON, BRUCE LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEE
Last Name:DAWSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-3423
Mailing Address - Country:US
Mailing Address - Phone:515-255-4211
Mailing Address - Fax:515-255-4196
Practice Address - Street 1:4313 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-3423
Practice Address - Country:US
Practice Address - Phone:515-255-4211
Practice Address - Fax:515-255-4196
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA750103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA43675OtherWELLMARK BCBS
IA0199497Medicaid
IA0199497Medicaid