Provider Demographics
NPI:1184303521
Name:SALAZAR, MARK ANTHONY (CAS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:CAS
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:ANTHONY
Other - Last Name:SALAZAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CAS
Mailing Address - Street 1:275 W ABRIENDO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1870
Mailing Address - Country:US
Mailing Address - Phone:719-621-1929
Mailing Address - Fax:
Practice Address - Street 1:275 W ABRIENDO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1870
Practice Address - Country:US
Practice Address - Phone:719-621-1929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0997499101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)