MEDICARE: MOLLY K GERONAZZO LPC

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	101YP2500X	Professional Counselor	3821	CO

General Provider Information

NPI Number	:	1770689770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY K GERONAZZO LPC

Provider Business Mailing Address
First Line	:	5470 SAMPLE WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-2491
Country	:	US
Telephone Number	:	719-640-0793
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 S CASCADE AVE STE C
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-4050
Country	:	US
Telephone Number	:	719-640-0793
Fax Number	:	719-471-2023

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	03/29/2019

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