Healthcare Provider Details

I. General information

NPI: 1578712790
Provider Name (Legal Business Name): ALLYSON ELAINE HACKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 1/2 CRESTONE AVE
COLORADO SPRINGS CO
80905-2142
US

IV. Provider business mailing address

1512 1/2 CRESTONE AVE
COLORADO SPRINGS CO
80905-2142
US

V. Phone/Fax

Practice location:
  • Phone: 719-439-9608
  • Fax:
Mailing address:
  • Phone: 719-439-9608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number439
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: