Basic Information
| Provider Information | |||||||||
| NPI: | 1063415560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TACHA | ||||||||
| FirstName: | LUCINDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 6TH ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808212002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | 7193447817 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 1ST ST. | ||||||||
| Address2: | |||||||||
| City: | LIMON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808281120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197752367 | ||||||||
| FaxNumber: | 7197752365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 992478 | CO | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 92226779 | 05 | CO | MEDICAID |