MEDICARE: BERTEN DRAGTEN PH.D.

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		CO

General Provider Information

NPI Number	:	1427156975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERTEN DRAGTEN PH.D.

Provider Business Mailing Address
First Line	:	614 N NEVADA AVE
Second Line	:	SUITE 101A
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-5021
Country	:	US
Telephone Number	:	719-630-3696
Fax Number	:

Provider Business Practice Location Address
First Line	:	614 N NEVADA AVE
Second Line	:	SUITE 101A
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-5021
Country	:	US
Telephone Number	:	719-630-3696
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/26/2007

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