Basic Information
| Provider Information | |||||||||
| NPI: | 1598280257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALDERON | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 417 W 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199947643 | ||||||||
| FaxNumber: | 7195442033 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 W 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199947643 | ||||||||
| FaxNumber: | 7195442033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2017 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC.0013624 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 9000150372 | 05 | CO | MEDICAID |