MEDICARE: DR. ADRIENNE PANTER PSYD, LPC

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	0012827	CO
2	101YP2500X	Professional Counselor	0012827	CO
3	103TC0700X	Clinical Psychologist	PSY.0005030	CO

General Provider Information

NPI Number	:	1487107512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADRIENNE PANTER PSYD, LPC

Provider Business Mailing Address
First Line	:	PO BOX 608
Second Line	:
City	:	PAGOSA SPRINGS
State	:	CO
Zip	:	81147-0608
Country	:	US
Telephone Number	:	970-946-8123
Fax Number	:

Provider Business Practice Location Address
First Line	:	1032 1/2 MAIN AVE
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-5124
Country	:	US
Telephone Number	:	970-946-8123
Fax Number	:	970-764-4592

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2016
Last Update Date	:	11/10/2020

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