Healthcare Provider Details

I. General information

NPI: 1538589254
Provider Name (Legal Business Name): PAITTON NICOLE KENDRICK-CALLERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HARVARD AVE
PUEBLO CO
81004-1223
US

IV. Provider business mailing address

123 HARVARD AVE
PUEBLO CO
81004-1223
US

V. Phone/Fax

Practice location:
  • Phone: 918-658-8352
  • Fax:
Mailing address:
  • Phone: 918-658-8352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC.0020849
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number24-107
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: