MEDICARE: WAHLBERG COUNSELING SERVICES

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	1041C0700X	Clinical Social Worker	00002014	CO

General Provider Information

NPI Number	:	1619367901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAHLBERG COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	5855 LEHMAN DR STE 201
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3492
Country	:	US
Telephone Number	:	719-271-6306
Fax Number	:	719-362-4390

Provider Business Practice Location Address
First Line	:	5855 LEHMAN DR STE 201
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3492
Country	:	US
Telephone Number	:	719-271-6306
Fax Number	:	719-362-4390

Authorized Official
Title or Position	:	OWNER
Name	:	NYKOL R WAHLBERG
Credential	:	LCSW
Telephone Number	:	719-271-6306

Provider Enumeration Date	:	01/26/2015
Last Update Date	:	04/23/2024

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