Healthcare Provider Details

I. General information

NPI: 1033417605
Provider Name (Legal Business Name): AMANDA HASENACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MONTEBELLO RD STE LL1
PUEBLO CO
81001-1379
US

IV. Provider business mailing address

41 MONTEBELLO RD STE 204
PUEBLO CO
81001-1379
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-2746
  • Fax: 719-545-4100
Mailing address:
  • Phone: 719-545-2746
  • Fax: 719-545-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0024331
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0002778
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: