Basic Information
| Provider Information | |||||||||
| NPI: | 1821354531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RASZKA | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED., BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 590 W HIGHWAY 105 STE 105 | ||||||||
| Address2: | |||||||||
| City: | MONUMENT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801329125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196495037 | ||||||||
| FaxNumber: | 7193688399 | ||||||||
| Practice Location | |||||||||
| Address1: | 590 W HIGHWAY 105 STE 105 | ||||||||
| Address2: | |||||||||
| City: | MONUMENT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801329125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196495037 | ||||||||
| FaxNumber: | 7193688399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2012 | ||||||||
| LastUpdateDate: | 05/09/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-13-14747 | CO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 26780089 | 05 | CO | MEDICAID |