MEDICARE: JAMES B CARDINAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	101YM0800X	Mental Health Counselor	LPP1145	CO

General Provider Information

NPI Number	:	1104284413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES B CARDINAL

Provider Business Mailing Address
First Line	:	4211 HIDEOUT PL
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81008-1878
Country	:	US
Telephone Number	:	719-240-2668
Fax Number	:

Provider Business Practice Location Address
First Line	:	3585 VAN TEYLINGEN DR STE D
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4872
Country	:	US
Telephone Number	:	719-413-5005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2016
Last Update Date	:	10/01/2023

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