Healthcare Provider Details

I. General information

NPI: 1992079925
Provider Name (Legal Business Name): KRISTINA LYNN CARRERA MSW, LCSW, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINE LYNN SCULL MSW

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 S PRAIRIE AVE
PUEBLO CO
81005-2886
US

IV. Provider business mailing address

220 RUSKIN DRIVE
COLORADO SPRINGS CO
80910
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-5070
  • Fax: 719-896-2874
Mailing address:
  • Phone: 719-572-6100
  • Fax: 719-447-4792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1057
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09923606
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: