Healthcare Provider Details

I. General information

NPI: 1013831635
Provider Name (Legal Business Name): MARY LISA DECELLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 MARK DABLING BLVD STE 102
COLORADO SPRINGS CO
80918-3847
US

IV. Provider business mailing address

5475 MARK DABLING BLVD STE 102
COLORADO SPRINGS CO
80918-3847
US

V. Phone/Fax

Practice location:
  • Phone: 719-641-0448
  • Fax:
Mailing address:
  • Phone: 719-641-0448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-312673
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: