Provider Demographics
NPI:1477101517
Name:PALMER, IDALIAS MELIA SAMSON (RBT)
Entity type:Individual
Prefix:
First Name:IDALIAS
Middle Name:MELIA SAMSON
Last Name:PALMER
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7237 MAYBECK VW
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-4739
Mailing Address - Country:US
Mailing Address - Phone:719-761-4189
Mailing Address - Fax:
Practice Address - Street 1:5165 BALSAM ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-5144
Practice Address - Country:US
Practice Address - Phone:719-425-8702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-02
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician