Healthcare Provider Details

I. General information

NPI: 1477478246
Provider Name (Legal Business Name): ANGELINA FACKELMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4512 ANVIL DR
COLORADO SPRINGS CO
80925-1034
US

IV. Provider business mailing address

4512 ANVIL DR
COLORADO SPRINGS CO
80925-1034
US

V. Phone/Fax

Practice location:
  • Phone: 201-696-2420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADDC.0000783
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPCC.0025041
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: