Provider Demographics
NPI:1790223634
Name:PALM, CONNIE (CAC III)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:PALM
Suffix:
Gender:F
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 BONFORTE BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1602
Mailing Address - Country:US
Mailing Address - Phone:719-404-1992
Mailing Address - Fax:719-404-1996
Practice Address - Street 1:1615 BONFORTE BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1602
Practice Address - Country:US
Practice Address - Phone:719-404-1992
Practice Address - Fax:719-404-1996
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7136101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)