Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor | 112140114 | CO |
NPI | 1215314695 |
---|---|
Provider Name | Gus David Holabeck III |
First Address | Colorado Springs, CO 80923-7549 |
Second Address | Castle Rock, CO 80104-2434 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/05/2015 |
Last Update Date | 05/05/2015 |