Healthcare Provider Details

I. General information

NPI: 1720054851
Provider Name (Legal Business Name): FRED GAGLIARDI MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 OUTLOOK BLVD
PUEBLO CO
81008-1667
US

IV. Provider business mailing address

51 VERDOSA DR
PUEBLO CO
81005-2942
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-1081
  • Fax: 719-553-1107
Mailing address:
  • Phone: 719-561-1892
  • Fax: 719-553-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number992290
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: