1265648364 NPI number — DR. DAVID LEROY FENELL PHD

Table of content: DR. DAVID LEROY FENELL PHD (NPI 1265648364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265648364 NPI number — DR. DAVID LEROY FENELL PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENELL
Provider First Name:
DAVID
Provider Middle Name:
LEROY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265648364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7665 YELLOWWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80920-6622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-590-1252
Provider Business Mailing Address Fax Number:
719-262-4110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UNIVERSITY OF COLORADO COLLEGE OF EDUCATION
Provider Second Line Business Practice Location Address:
1420 AUSTIN BLUFFS PARKWAY
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80933-7150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-262-4096
Provider Business Practice Location Address Fax Number:
719-262-4110
Provider Enumeration Date:
05/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  PSYCHOLOGIST-1055 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)