Healthcare Provider Details

I. General information

NPI: 1790299725
Provider Name (Legal Business Name): MI CASA TRANSITIONAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 CRESTMOOR DR
PUEBLO CO
81001-2727
US

IV. Provider business mailing address

1611 CRESTMOOR DR
PUEBLO CO
81001-2727
US

V. Phone/Fax

Practice location:
  • Phone: 719-214-4755
  • Fax:
Mailing address:
  • Phone: 719-214-4755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0000444
License Number StateCO

VIII. Authorized Official

Name: LISA M PAYNE
Title or Position: OFFICIAL AGENT
Credential: COTA/L
Phone: 719-214-4755