Healthcare Provider Details

I. General information

NPI: 1942029459
Provider Name (Legal Business Name): ITZA CORAZON COMMUNITY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 N CHELTON RD STE 210
COLORADO SPRINGS CO
80909-5256
US

IV. Provider business mailing address

1160 LAKE PLAZA DR STE 200
COLORADO SPRINGS CO
80906-3507
US

V. Phone/Fax

Practice location:
  • Phone: 710-500-6009
  • Fax:
Mailing address:
  • Phone: 719-500-6009
  • Fax: 719-890-7162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: PEDRO F RIDDELL
Title or Position: CEO
Credential: LSW, LACC
Phone: 530-786-9882