MEDICARE: ACTION BEHAVIOR CENTERS, 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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1295432409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTION BEHAVIOR CENTERS, LLC

Provider Business Mailing Address
First Line	:	1601 S MOPAC EXPY
Second Line	:	C 300
City	:	AUSTIN
State	:	TX
Zip	:	78746-7077
Country	:	US
Telephone Number	:	512-551-1717
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 SPECHT POINT RD
Second Line	:	SUITE 105
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4361
Country	:	US
Telephone Number	:	970-305-9200
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	SAMANTHA L GOMEZ
Credential	:
Telephone Number	:	512-551-1717

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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