Healthcare Provider Details

I. General information

NPI: 1225457377
Provider Name (Legal Business Name): JUDITH FAY VISNACK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 PHAY AVE STE E
CANON CITY CO
81212-2349
US

IV. Provider business mailing address

1335 PHAY AVE STE E
CANON CITY CO
81212-2349
US

V. Phone/Fax

Practice location:
  • Phone: 719-276-0801
  • Fax: 719-275-4305
Mailing address:
  • Phone: 719-276-0801
  • Fax: 719-275-4305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4116
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: