Provider Demographics
NPI:1710051834
Name:ENVISION-CREATIVE SUPPORT FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:ENVISION-CREATIVE SUPPORT FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:EWERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-339-5360
Mailing Address - Street 1:PO BOX 200069
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-0069
Mailing Address - Country:US
Mailing Address - Phone:970-339-5360
Mailing Address - Fax:970-330-2261
Practice Address - Street 1:1050 37TH ST
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-2115
Practice Address - Country:US
Practice Address - Phone:970-339-5360
Practice Address - Fax:970-330-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09145764Medicaid
CO09139676Medicaid
CO50057367Medicaid