Healthcare Provider Details

I. General information

NPI: 1164367165
Provider Name (Legal Business Name): TINA BISPO CAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 E 13TH ST
PUEBLO CO
81001-2940
US

IV. Provider business mailing address

509 E 13TH ST
PUEBLO CO
81001-2940
US

V. Phone/Fax

Practice location:
  • Phone: 719-546-6666
  • Fax: 719-404-1917
Mailing address:
  • Phone: 719-546-6666
  • Fax: 719-404-1917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACC.0021392
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: