Provider Demographics
NPI:1235261637
Name:COLORADO MENTAL HEALTH INSTITUTE PUEBLO
Entity Type:Organization
Organization Name:COLORADO MENTAL HEALTH INSTITUTE PUEBLO
Other - Org Name:FORENSIC UNDER 21
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAPP
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:720-701-2169
Mailing Address - Street 1:1600 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1411
Mailing Address - Country:US
Mailing Address - Phone:719-546-4000
Mailing Address - Fax:719-546-4484
Practice Address - Street 1:1600 W 24TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1411
Practice Address - Country:US
Practice Address - Phone:719-546-4000
Practice Address - Fax:719-546-4484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0295273R00000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88977048Medicaid
CO03211885Medicaid