Basic Information
| Provider Information | |||||||||
| NPI: | 1790036440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MSW, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VACHA | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 115 S PARKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2012 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW.09924271 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.