Provider Demographics
NPI:1144594458
Name:SUSAN DOLAN
Entity Type:Organization
Organization Name:SUSAN DOLAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:719-278-9536
Mailing Address - Street 1:5525 ERINDALE DR
Mailing Address - Street 2:STE. #107
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6740
Mailing Address - Country:US
Mailing Address - Phone:719-278-9536
Mailing Address - Fax:719-266-6025
Practice Address - Street 1:5525 ERINDALE DR
Practice Address - Street 2:STE. #107
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6740
Practice Address - Country:US
Practice Address - Phone:719-278-9536
Practice Address - Fax:719-266-6025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSAN DOLAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO991699251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO155048Medicaid
CO155048Medicaid