=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841608577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PENNY ALLEN CACIII
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2014
-----------------------------------------------------
Last Update Date | 07/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 N MAIN ST SUITE 214
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81003-3196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-214-3033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 N MAIN ST SUITE 214
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81003-3196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-214-3033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1544
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------