MEDICARE: SERENA SOWIN

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	103TS0200X	School Psychologist	409592	NM

General Provider Information

NPI Number	:	1376271718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERENA SOWIN

Provider Business Mailing Address
First Line	:	6460 MESEDGE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-1813
Country	:	US
Telephone Number	:	408-893-8028
Fax Number	:

Provider Business Practice Location Address
First Line	:	6460 MESEDGE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-1813
Country	:	US
Telephone Number	:	408-893-8028
Fax Number	:

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

Provider Enumeration Date	:	08/12/2022
Last Update Date	:	08/12/2022

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