Provider Demographics
NPI:1033997465
Name:MGA BEHAVIOR THERAPY LLC
Entity Type:Organization
Organization Name:MGA BEHAVIOR THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLOSKUS
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:720-276-7706
Mailing Address - Street 1:1355 GARDEN OF THE GODS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3595
Mailing Address - Country:US
Mailing Address - Phone:719-212-6535
Mailing Address - Fax:
Practice Address - Street 1:3400 WALSH PKWY STE 248
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1642
Practice Address - Country:US
Practice Address - Phone:910-839-0239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MGA BEHAVIOR THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health