Healthcare Provider Details

I. General information

NPI: 1225207400
Provider Name (Legal Business Name): SOARING EAGLES CENTER FOR AUTISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W PALMER LAKE DR
PUEBLO WEST CO
81007-2876
US

IV. Provider business mailing address

PO BOX 7878
PUEBLO WEST CO
81007-0878
US

V. Phone/Fax

Practice location:
  • Phone: 719-547-8803
  • Fax: 719-547-8806
Mailing address:
  • Phone: 719-547-8803
  • Fax: 719-547-8806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34666
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number34666
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-30000
License Number StateCO

VIII. Authorized Official

Name: DR. KAREN W. COLVIN
Title or Position: EXECUTIVE DIRECTOR
Credential: M.D.
Phone: 719-547-8803