=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467938589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK MAXWELL ZIEGENHAGEN MA, MFTC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2018
-----------------------------------------------------
Last Update Date | 07/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7680 GODDARD ST STE 216
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80920-8232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-299-1626
-----------------------------------------------------
Fax | 970-658-1027
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7680 GODDARD ST STE 216
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80920-8232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-338-3329
-----------------------------------------------------
Fax | 970-658-1027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFTC.0013684
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------