Healthcare Provider Details

I. General information

NPI: 1649000274
Provider Name (Legal Business Name): CHILDREN'S SPECIALTY CLINIC OF SAN LUIS VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 RUPERT ST
MONTE VISTA CO
81144-1042
US

IV. Provider business mailing address

10 RUPERT ST
MONTE VISTA CO
81144-1042
US

V. Phone/Fax

Practice location:
  • Phone: 719-852-3742
  • Fax:
Mailing address:
  • Phone: 719-852-3742
  • Fax: 719-852-2559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L CLUTTER
Title or Position: CHIEF OF OPERATIONS
Credential:
Phone: 719-852-3742