Organization
IMPACT COUNSELING CONSULTING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MYRA FAIRLINE RICKETTS (DIRECTOR)
(352) 587-2378
Entity
Organization
Contact information
Practice address
4 AVIS AVE, PUEBLO, CO 81005-3102
(719) 256-1327
Mailing address
4 AVIS AVE, PUEBLO, CO 81005-3102
(719) 256-1327
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9000202666
—
CO
Enumeration date
11/15/2022
Last updated
11/15/2022
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