MEDICARE: MS. KIMBERLY ANN SANDUSKY

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	1041C0700X	Clinical Social Worker	000081	GU

General Provider Information

NPI Number	:	1144525197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY ANN SANDUSKY

Provider Business Mailing Address
First Line	:	990 BAYFIELD WAY
Second Line	:	#201
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4627
Country	:	US
Telephone Number	:	719-357-3072
Fax Number	:

Provider Business Practice Location Address
First Line	:	1853 OCONNELL BLVD
Second Line	:	BLDG 1056
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4055
Country	:	US
Telephone Number	:	719-526-6748
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2011
Last Update Date	:	01/24/2011

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