Basic Information
| Provider Information | |||||||||
| NPI: | 1992882963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIMATTEO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSW,LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 E PARKRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810071377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195473263 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1304 CHINOOK LN | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810011851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195452746 | ||||||||
| FaxNumber: | 7195840110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 692 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.