Organization
BUCK JACK LLC
Active
Other names
The Shandy Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM COLT (PRESIDENT)
(713) 410-6889
Entity
Organization
Contact information
Practice address
6190 BARNES RD, COLORADO SPRINGS, CO 80922-2600
(719) 247-1511
(719) 599-4606
Mailing address
685 CITADEL DR E STE 580, COLORADO SPRINGS, CO 80909-5381
(713) 725-9181
(719) 599-4606
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
—
—
103T00000X
Psychologist
—
—
225100000X
Physical Therapist
—
—
225X00000X
Occupational Therapist
—
—
235Z00000X
Speech-Language Pathologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9000181601
—
CO
Enumeration date
08/11/2020
Last updated
10/01/2020
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