Healthcare Provider Details

I. General information

NPI: 1730699984
Provider Name (Legal Business Name): ADULT YOUTH @ SWANSON COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W 4TH ST STE D
PUEBLO CO
81003-2392
US

IV. Provider business mailing address

803 W 4TH ST STE D
PUEBLO CO
81003-2392
US

V. Phone/Fax

Practice location:
  • Phone: 719-225-8639
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACB7020
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCSWOO923464
License Number StateCO

VIII. Authorized Official

Name: TIMOTHY SWANSON
Title or Position: OWNER
Credential:
Phone: 719-641-4917