Basic Information
| Provider Information | |||||||||
| NPI: | 1063699825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAIME | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNDA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GONZALES | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LYNDA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1603 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810524044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193363647 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3500 1ST ST S | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810524327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193367501 | ||||||||
| FaxNumber: | 7193367453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.