MEDICARE: MGA BEHAVIOR THERAPY 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1033997465
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MGA BEHAVIOR THERAPY LLC

Provider Business Mailing Address
First Line	:	1355 GARDEN OF THE GODS RD STE 130
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-3595
Country	:	US
Telephone Number	:	719-212-6535
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 WALSH PKWY STE 248
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-1642
Country	:	US
Telephone Number	:	910-839-0239
Fax Number	:

Authorized Official
Title or Position	:	CHIEF COMPLIANCE OFFICER
Name	:	ALEXANDRA KOLOSKUS
Credential	:	ESQ
Telephone Number	:	720-276-7706

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	09/18/2023

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