Healthcare Provider Details

I. General information

NPI: 1710436910
Provider Name (Legal Business Name): MEGAN MARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 COLORADO AVE
PUEBLO CO
81004-2046
US

IV. Provider business mailing address

550 S WATERMELON DR
PUEBLO WEST CO
81007-2826
US

V. Phone/Fax

Practice location:
  • Phone: 719-948-7120
  • Fax:
Mailing address:
  • Phone: 614-738-1785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0004026
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: