Provider Demographics
NPI:1992772370
Name:DEPARTMENT OF DEFENSE
Entity type:Organization
Organization Name:DEPARTMENT OF DEFENSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUBSTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELSA
Authorized Official - Middle Name:U
Authorized Official - Last Name:LONGRES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCDC
Authorized Official - Phone:719-526-2862
Mailing Address - Street 1:3863 JOSEPHINE HTS
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-5080
Mailing Address - Country:US
Mailing Address - Phone:719-526-2862
Mailing Address - Fax:719-526-0608
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4603
Practice Address - Country:US
Practice Address - Phone:719-526-2862
Practice Address - Fax:719-526-0608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28781286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7935OtherLCDC
TX28781OtherLCSW