Healthcare Provider Details

I. General information

NPI: 1669136941
Provider Name (Legal Business Name): CAROLYN MARIE YEAGER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2021
Last Update Date: 10/24/2021
Certification Date: 10/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 WOODMEN MESA CIR
COLORADO SPRINGS CO
80919-2529
US

IV. Provider business mailing address

7330 WOODMEN MESA CIR
COLORADO SPRINGS CO
80919-2529
US

V. Phone/Fax

Practice location:
  • Phone: 719-645-1680
  • Fax:
Mailing address:
  • Phone: 719-645-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY.0005666
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: