Provider Demographics
NPI:1083775498
Name:COSYLEON, PRUDENCIO (LCSW)
Entity type:Individual
Prefix:
First Name:PRUDENCIO
Middle Name:
Last Name:COSYLEON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E ROUTT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2117
Mailing Address - Country:US
Mailing Address - Phone:719-543-8711
Mailing Address - Fax:
Practice Address - Street 1:417 W 13TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2703
Practice Address - Country:US
Practice Address - Phone:719-544-0877
Practice Address - Fax:719-544-2033
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9914321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO350465YLQPOtherMEDICARE
CO02259800Medicaid
CO02259800Medicaid