Provider Demographics
NPI:1245513399
Name:PROJECT PUEBLO
Entity type:Organization
Organization Name:PROJECT PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:R
Authorized Official - Last Name:POTEET
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:303-908-8623
Mailing Address - Street 1:117 FAIRWAY VLG
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-3621
Mailing Address - Country:US
Mailing Address - Phone:303-908-8623
Mailing Address - Fax:
Practice Address - Street 1:117 FAIRWAY VLG
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-3621
Practice Address - Country:US
Practice Address - Phone:303-908-8623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW 1809251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health