MEDICARE: MARGOT DE VITA PHD

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	103TC0700X	Clinical Psychologist	2649	CO

General Provider Information

NPI Number	:	1295021186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARGOT DE VITA PHD

Provider Business Mailing Address
First Line	:	1720 JET STREAM DR STE 202
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3938
Country	:	US
Telephone Number	:	719-685-7869
Fax Number	:	719-685-7870

Provider Business Practice Location Address
First Line	:	1720 JET STREAM DR STE 202
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3938
Country	:	US
Telephone Number	:	719-685-7869
Fax Number	:	719-685-7870

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

Provider Enumeration Date	:	06/20/2011
Last Update Date	:	08/10/2012

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