Provider Demographics
NPI:1134556541
Name:MCDONALD, CONSTANCE L (CAC III)
Entity type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:L
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2429
Mailing Address - Country:US
Mailing Address - Phone:714-954-3564
Mailing Address - Fax:
Practice Address - Street 1:310 W C ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3409
Practice Address - Country:US
Practice Address - Phone:719-296-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7087101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)