MEDICARE: DATG LLC

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1588141451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DATG LLC

Provider Business Mailing Address
First Line	:	1237 N LAFAYETTE ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80218-2315
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	950 N LOGAN ST STE 301
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-3009
Country	:	US
Telephone Number	:	415-246-0712
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH STEVENSON
Credential	:	LMFT
Telephone Number	:	415-246-0712

Provider Enumeration Date	:	07/24/2018
Last Update Date	:	07/24/2018

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