MEDICARE: LEILANI ANISE WEDGLE RBT

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	106S00000X	Behavior Technician		CO
2	106S00000X	Behavior Technician	17-093-7386	CO

General Provider Information

NPI Number	:	1194425397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEILANI ANISE WEDGLE RBT

Provider Business Mailing Address
First Line	:	2524 SAN MARCOS DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-1242
Country	:	US
Telephone Number	:	719-447-7938
Fax Number	:

Provider Business Practice Location Address
First Line	:	3595 E FOUNTAIN BLVD STE 145
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-1791
Country	:	US
Telephone Number	:	254-630-1578
Fax Number	:

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

Provider Enumeration Date	:	03/06/2023
Last Update Date	:	03/06/2023

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Directions to “ LEILANI ANISE WEDGLE RBT” Practice Location

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