Basic Information
| Provider Information | |||||||||
| NPI: | 1063613644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILBERTSON | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 976 | ||||||||
| Address2: | |||||||||
| City: | LIMON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808280976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197752313 | ||||||||
| FaxNumber: | 7197752315 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | LIMON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197752313 | ||||||||
| FaxNumber: | 7197752315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 04/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3462 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 1600 | CO | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 42818 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 11839 | 05 | CO | MEDICAID |