MEDICARE: PRIMARY WITNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1477175701
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY WITNESS

Provider Business Mailing Address
First Line	:	1055 N LOGAN ST APT 1206
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-3040
Country	:	US
Telephone Number	:	303-875-0145
Fax Number	:

Provider Business Practice Location Address
First Line	:	1574 YORK ST STE 101
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80206-1248
Country	:	US
Telephone Number	:	303-875-0145
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. THIAGO LEAO
Credential	:	LPC
Telephone Number	:	303-875-0145

Provider Enumeration Date	:	05/08/2020
Last Update Date	:	05/08/2020

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Directions to “PRIMARY WITNESS ” Practice Location

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