Basic Information
| Provider Information | |||||||||
| NPI: | 1073949822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | ILENE | ||||||||
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| Credential: | MA,LPC, CAC II | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GONZALES | ||||||||
| OtherFirstName: | CYNTHIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1300 N 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806319584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703472120 | ||||||||
| FaxNumber: | 9703003133 | ||||||||
| Practice Location | |||||||||
| Address1: | 2930 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806201011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703481114 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 12/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ACB.0007359 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LPC.0014138 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.