Healthcare Provider Details

I. General information

NPI: 1407265291
Provider Name (Legal Business Name): EMILY FILLMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 CHINOOK LN
PUEBLO CO
81001-1851
US

IV. Provider business mailing address

41 MONTEBELLO RD SUITE 200
PUEBLO CO
81001-1379
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-2746
  • Fax: 719-584-0110
Mailing address:
  • Phone: 719-545-2746
  • Fax: 719-542-9638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09926697
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: