MEDICARE: CALVIN LIDMARK LPC, LAC, CCMHC, MAC

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	1098	CO
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	ACD-167	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11703979	OTHER	CO	CAQH

General Provider Information

NPI Number	:	1700983483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALVIN LIDMARK LPC, LAC, CCMHC, MAC

Provider Business Mailing Address
First Line	:	1650 COCHRANE CIR
Second Line	:	BLDG 7505, RM 163
City	:	FT CARSON
State	:	CO
Zip	:	80913-4604
Country	:	US
Telephone Number	:	719-526-6073
Fax Number	:	719-526-7732

Provider Business Practice Location Address
First Line	:	1638 ELWELL ST
Second Line	:	BLDG 6236, RM 229
City	:	FT CARSON
State	:	CO
Zip	:	80913-4356
Country	:	US
Telephone Number	:	719-526-2196
Fax Number	:	719-526-1983

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

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	09/03/2013

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