MEDICARE: REAL CONNECTIONS COUNSELING, 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	106H00000X	Marriage & Family Therapist	20131134448	CO

General Provider Information

NPI Number	:	1578918868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REAL CONNECTIONS COUNSELING, LLC

Provider Business Mailing Address
First Line	:	5555 ERINDALE DR
Second Line	:	SUITE 204
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-6736
Country	:	US
Telephone Number	:	719-419-7633
Fax Number	:

Provider Business Practice Location Address
First Line	:	5555 ERINDALE DR
Second Line	:	SUITE 204
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-6736
Country	:	US
Telephone Number	:	719-419-7633
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RICHARD J ELGERSMA
Credential	:	M.LITT, MA, MFTC
Telephone Number	:	719-419-7633

Provider Enumeration Date	:	04/25/2016
Last Update Date	:	04/25/2016

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