Basic Information
| Provider Information | |||||||||
| NPI: | 1700983483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIDMARK | ||||||||
| FirstName: | CALVIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC, LAC, CCMHC, MAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | BLDG 7505, RM 163 | ||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195266073 | ||||||||
| FaxNumber: | 7195267732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1638 ELWELL ST | ||||||||
| Address2: | BLDG 6236, RM 229 | ||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195262196 | ||||||||
| FaxNumber: | 7195261983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 09/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1098 | CO | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | ACD-167 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 11703979 | 01 | CO | CAQH | OTHER |