Provider Demographics
NPI:1952818817
Name:VITRO, AJA MARY (RBT)
Entity Type:Individual
Prefix:
First Name:AJA
Middle Name:MARY
Last Name:VITRO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 W PIKES PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-4356
Mailing Address - Country:US
Mailing Address - Phone:719-822-7902
Mailing Address - Fax:
Practice Address - Street 1:2760 FIELDSTONE RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3100
Practice Address - Country:US
Practice Address - Phone:719-203-6903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-01
Last Update Date:2018-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty