Provider Demographics
NPI:1942059118
Name:KOOGLE, MARIE J
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:J
Last Name:KOOGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17856 SMELTING ROCK DR
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-9210
Mailing Address - Country:US
Mailing Address - Phone:303-618-0933
Mailing Address - Fax:
Practice Address - Street 1:13725 STRUTHERS RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-2451
Practice Address - Country:US
Practice Address - Phone:719-301-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-24-345256106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician