=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295262426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES KODI KRANSBERGER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2017
-----------------------------------------------------
Last Update Date | 05/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6767 S SPRUCE ST STE 100
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80112-6118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-225-7673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 543 18TH ST UNIT 204
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80631-6035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-921-9417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | BACB375979
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------