Basic Information
| Provider Information | |||||||||
| NPI: | 1861479024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESANTIS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2828 INTERNATIONAL CIR | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 04/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 2690 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 64456722 | 05 | CO | MEDICAID | COA101696 | 01 | CO | MEDICARE NUMBER | OTHER |