MEDICARE: DELEIGN BOLLINGER BCBA

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	103K00000X	Behavior Analyst	1-16-24721	CO

General Provider Information

NPI Number	:	1316484140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DELEIGN BOLLINGER BCBA

Provider Business Mailing Address
First Line	:	685 CITADEL DR E STE 345
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5326
Country	:	US
Telephone Number	:	940-968-7105
Fax Number	:

Provider Business Practice Location Address
First Line	:	685 CITADEL DR E STE 345
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5326
Country	:	US
Telephone Number	:	719-540-2108
Fax Number	:	719-540-2101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	11/03/2017

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