MEDICARE: PHASE TWO COUNSELING SERVICE

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	302R00000X	Health Maintenance Organization	6148	CO

General Provider Information

NPI Number	:	1679896088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHASE TWO COUNSELING SERVICE

Provider Business Mailing Address
First Line	:	833 E PLATTE AVE
Second Line	:	L-3
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-5512
Country	:	US
Telephone Number	:	719-473-1805
Fax Number	:	719-302-5324

Provider Business Practice Location Address
First Line	:	833 E PLATTE AVE
Second Line	:	L-3
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-5512
Country	:	US
Telephone Number	:	719-473-1805
Fax Number	:	719-302-5324

Authorized Official
Title or Position	:	SOLE OWNER
Name	:	MRS. MARGIE R JONES-DUDLEY
Credential	:	MA
Telephone Number	:	719-473-1805

Provider Enumeration Date	:	03/12/2010
Last Update Date	:	03/12/2010

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