Provider Demographics
NPI:1992340319
Name:SAMUDIO, DUSTIN DEAN (BA PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:DEAN
Last Name:SAMUDIO
Suffix:
Gender:M
Credentials:BA PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 E DONALD AVE # D4909
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-5505
Mailing Address - Country:US
Mailing Address - Phone:507-369-8280
Mailing Address - Fax:
Practice Address - Street 1:1290 CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-7117
Practice Address - Country:US
Practice Address - Phone:303-617-2300
Practice Address - Fax:303-617-2365
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator