Basic Information
| Provider Information | |||||||||
| NPI: | 1366043531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAINTHOW | ||||||||
| FirstName: | NICOLLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 MONTEBELLO RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810011379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195452746 | ||||||||
| FaxNumber: | 7195454100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 W ABRIENDO AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810041128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195452746 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT.121367 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.