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NPI Code Detail

MEDICARE: SHASTA BRENSKE MS

MEDICARE: SHASTA BRENSKE MS
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
1103K00000XBehavior Analyst1-07-3748CO

General Provider Information

NPI Number : 1427468768
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHASTA BRENSKE MS
Provider Business Mailing Address
First Line : 104 W OLD BROADMOOR RD
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80906-3336
Country : US
Telephone Number : 214-901-4196
Fax Number :
Provider Business Practice Location Address
First Line : 4815 LIST DR STE 107
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80919-3340
Country : US
Telephone Number : 719-325-6311
Fax Number : 844-278-5902
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/07/2014
Last Update Date : 02/02/2021

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