=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235454802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN LEVAN CHAMBON LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2010
-----------------------------------------------------
Last Update Date | 04/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 627 N WEBER SUITE 4B
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-475-8286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 627 N WEBER SUITE 4B
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-475-8286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 1175
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------