MEDICARE: MOMENTUM BEHAVIORAL HEALTH

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1821502097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOMENTUM BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	13395 VOYAGER PARKWAY SUITE 130 #143
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-7677
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1838 REDBANK DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-2012
Country	:	US
Telephone Number	:	719-359-2336
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICAL DIRECTOR
Name	:	CAROLE EASTER
Credential	:
Telephone Number	:	719-359-2336

Provider Enumeration Date	:	11/27/2017
Last Update Date	:	11/27/2017

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