Provider Demographics
NPI:1356611677
Name:MAES, ROBERT RICHARD (CAC III)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RICHARD
Last Name:MAES
Suffix:
Gender:M
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 1:279 S JOE MARTINEZ BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-5439
Mailing Address - Country:US
Mailing Address - Phone:719-647-1787
Mailing Address - Fax:719-647-1731
Practice Address - Street 1:279 S JOE MARTINEZ BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-5439
Practice Address - Country:US
Practice Address - Phone:719-647-1787
Practice Address - Fax:719-647-1731
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6520Medicaid