Provider Demographics
NPI:1700983483
Name:LIDMARK, CALVIN (LPC, LAC, CCMHC, MAC)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:LIDMARK
Suffix:
Gender:M
Credentials:LPC, LAC, CCMHC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:BLDG 7505, RM 163
Mailing Address - City:FT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4604
Mailing Address - Country:US
Mailing Address - Phone:719-526-6073
Mailing Address - Fax:719-526-7732
Practice Address - Street 1:1638 ELWELL ST
Practice Address - Street 2:BLDG 6236, RM 229
Practice Address - City:FT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4356
Practice Address - Country:US
Practice Address - Phone:719-526-2196
Practice Address - Fax:719-526-1983
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1098101YP2500X
COACD-167101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11703979OtherCAQH