Healthcare Provider Details

I. General information

NPI: 1245513399
Provider Name (Legal Business Name): PROJECT PUEBLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 FAIRWAY VLG
PUEBLO WEST CO
81007-3621
US

IV. Provider business mailing address

117 FAIRWAY VLG
PUEBLO WEST CO
81007-3621
US

V. Phone/Fax

Practice location:
  • Phone: 303-908-8623
  • Fax:
Mailing address:
  • Phone: 303-908-8623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCSW 1809
License Number StateCO

VIII. Authorized Official

Name: MR. EARL R POTEET
Title or Position: PRESIDENT
Credential: LCSW
Phone: 303-908-8623