Basic Information
| Provider Information | |||||||||
| NPI: | 1376273003 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CBLG RESIDENTIAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 N ACADEMY BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194664809 | ||||||||
| FaxNumber: | 7193688399 | ||||||||
| Practice Location | |||||||||
| Address1: | 2920 N ACADEMY BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194664809 | ||||||||
| FaxNumber: | 7193688399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2022 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDS | ||||||||
| AuthorizedOfficialFirstName: | JACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | HR | ||||||||
| AuthorizedOfficialTelephone: | 7194664809 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELIZABETH RASZKA CONSULTING | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.