MEDICARE: MRS. NYKOL R. WAHLBERG MSW, LCSW

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	104100000X	Social Worker	3296	ND
2	104100000X	Social Worker
3	1041C0700X	Clinical Social Worker	2014	CO

General Provider Information

NPI Number	:	1457585416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NYKOL R. WAHLBERG MSW, LCSW

Provider Business Mailing Address
First Line	:	5855 LEHMAN DR STE 201
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3492
Country	:	US
Telephone Number	:	719-271-6306
Fax Number	:	719-362-4390

Provider Business Practice Location Address
First Line	:	5855 LEHMAN DR STE 201
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3492
Country	:	US
Telephone Number	:	719-271-6306
Fax Number	:	719-362-4390

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

Provider Enumeration Date	:	05/06/2009
Last Update Date	:	06/04/2024

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