Basic Information
| Provider Information | |||||||||
| NPI: | 1992772370 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF DEFENSE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3863 JOSEPHINE HTS | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809065080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195262862 | ||||||||
| FaxNumber: | 7195260608 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | |||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195262862 | ||||||||
| FaxNumber: | 7195260608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONGRES | ||||||||
| AuthorizedOfficialFirstName: | ELSA | ||||||||
| AuthorizedOfficialMiddleName: | U | ||||||||
| AuthorizedOfficialTitleorPosition: | SUBSTANCE ABUSE COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 7195262862 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW, LCDC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 28781 | TX | Y | Hospitals | Military Hospital |
ID Information
| ID | Type | State | Issuer | Description | 7935 | 01 | TX | LCDC | OTHER | 28781 | 01 | TX | LCSW | OTHER |