Provider Demographics
NPI:1467599506
Name:MARRIAGE AND FAMILY TREATMENT CENTER
Entity Type:Organization
Organization Name:MARRIAGE AND FAMILY TREATMENT CENTER
Other - Org Name:PENROSE ST. FRANCIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:BUSCARELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:719-520-1711
Mailing Address - Street 1:218 E CACHE LA POUDRE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2903
Mailing Address - Country:US
Mailing Address - Phone:719-520-1711
Mailing Address - Fax:719-520-0236
Practice Address - Street 1:218 E CACHE LA POUDRE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2903
Practice Address - Country:US
Practice Address - Phone:719-520-1711
Practice Address - Fax:719-520-0236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO263251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO070498Medicaid