MEDICARE: PIKES PEAK PSYCHOTHERAPY, INC.

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	106H00000X	Marriage & Family Therapist	450	CO

General Provider Information

NPI Number	:	1265654693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIKES PEAK PSYCHOTHERAPY, INC.

Provider Business Mailing Address
First Line	:	2130 ACADEMY CIR
Second Line	:	SUITE B
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1694
Country	:	US
Telephone Number	:	719-761-4444
Fax Number	:	719-550-4100

Provider Business Practice Location Address
First Line	:	2130 ACADEMY CIR
Second Line	:	SUITE B
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1694
Country	:	US
Telephone Number	:	719-761-4444
Fax Number	:	719-550-4100

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHANDRA SEKHAR NAGIREDDY
Credential	:	PH.D
Telephone Number	:	719-761-4444

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	02/21/2012

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