Provider Demographics
NPI:1720594526
Name:EWOLDT, DIANA DOROTHEA (BCABA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:DOROTHEA
Last Name:EWOLDT
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 STETSON HILLS BLVD # 150
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3571
Mailing Address - Country:US
Mailing Address - Phone:719-209-2102
Mailing Address - Fax:
Practice Address - Street 1:4905 N UNION BLVD STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4058
Practice Address - Country:US
Practice Address - Phone:970-219-9089
Practice Address - Fax:719-465-2744
Is Sole Proprietor?:No
Enumeration Date:2017-12-17
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-18-9265106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst