MEDICARE: SUMMIT PSYCHOLOGICAL ASSESSMENT & CONSULTATION

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	103TB0200X	Cognitive & Behavioral Psychologist

General Provider Information

NPI Number	:	1598156994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMIT PSYCHOLOGICAL ASSESSMENT & CONSULTATION

Provider Business Mailing Address
First Line	:	7710 N UNION BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-4030
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7710 N UNION BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-4030
Country	:	US
Telephone Number	:	719-641-3748
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. BRIANA MAKOFSKE
Credential	:
Telephone Number	:	719-641-3748

Provider Enumeration Date	:	02/07/2015
Last Update Date	:	02/07/2015

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