Healthcare Provider Details

I. General information

NPI: 1376046292
Provider Name (Legal Business Name): LONNIE MCCARRON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EVANS RD FREMONT CORRECTIONAL FACILITY
CANON CITY CO
81212
US

IV. Provider business mailing address

1250 OAK HILLS DR
COLORADO SPRINGS CO
80919-1429
US

V. Phone/Fax

Practice location:
  • Phone: 719-269-5100
  • Fax:
Mailing address:
  • Phone: 719-264-8150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09925240
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: