Provider Demographics
NPI:1275814014
Name:ELIZALDE, JOSE L (LCSW)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:ELIZALDE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BUCK CREEK RD #200
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620
Mailing Address - Country:US
Mailing Address - Phone:970-926-6340
Mailing Address - Fax:
Practice Address - Street 1:50 BUCK CREEK RD #200
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620
Practice Address - Country:US
Practice Address - Phone:970-926-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
COCSW.099247731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty