MEDICARE: GUS DAVID HOLABECK III MA

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	101YP1600X	Pastoral Counselor	112140114	CO

General Provider Information

NPI Number	:	1215314695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUS DAVID HOLABECK III MA

Provider Business Mailing Address
First Line	:	6047 WHETSTONE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-7549
Country	:	US
Telephone Number	:	719-428-9283
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 PERRY ST STE 206E
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-2434
Country	:	US
Telephone Number	:	719-428-9283
Fax Number	:

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

Provider Enumeration Date	:	05/05/2015
Last Update Date	:	05/05/2015

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