MEDICARE: DR. BRIAN W DESANTIS PSY.D,

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	103TC2200X	Clinical Child & Adolescent Psychologist	2690	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	COA101696	OTHER	CO	MEDICARE NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861479024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN W DESANTIS PSY.D,

Provider Business Mailing Address
First Line	:	3205 N ACADEMY BLVD
Second Line	:	SUITE 130
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-5147
Country	:	US
Telephone Number	:	719-632-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	2828 INTERNATIONAL CIR
Second Line	:	SUITE 140
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3127
Country	:	US
Telephone Number	:	719-632-5700
Fax Number	:

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	04/03/2017

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