Basic Information
| Provider Information | |||||||||
| NPI: | 1114170578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ERSPAMER | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2864 S CIRCLE DR | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809064114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193142536 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2008 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.