MEDICARE: EMDR RESOLUTIONS LLC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1710473178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMDR RESOLUTIONS LLC

Provider Business Mailing Address
First Line	:	1355 S 8TH ST STE 206
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-7022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1355 S 8TH ST STE 206
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-7022
Country	:	US
Telephone Number	:	719-638-8844
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALIN
Name	:	JESS THORNBERRY
Credential	:
Telephone Number	:	719-638-8844

Provider Enumeration Date	:	07/09/2018
Last Update Date	:	07/09/2018

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