Healthcare Provider Details

I. General information

NPI: 1033352240
Provider Name (Legal Business Name): SUCAP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 MOUACHE RD.
IGNACIO CO
81137-0429
US

IV. Provider business mailing address

296 MOUACHE RD.
IGNACIO CO
81137-0429
US

V. Phone/Fax

Practice location:
  • Phone: 970-563-4555
  • Fax: 970-563-4618
Mailing address:
  • Phone: 970-563-4555
  • Fax: 970-563-4618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1445
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number116600
License Number StateCO

VIII. Authorized Official

Name: ELAINE WASSERBACH
Title or Position: DIRECTOR
Credential: M.A.
Phone: 970-563-4517