MEDICARE: RADIANT PSYCHOTHERAPY, 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	104100000X	Social Worker	899	CO

General Provider Information

NPI Number	:	1871846568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANT PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	190 E 9TH AVE STE 190
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-2744
Country	:	US
Telephone Number	:	303-859-7630
Fax Number	:	720-398-3263

Provider Business Practice Location Address
First Line	:	190 E 9TH AVE STE 190
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-2744
Country	:	US
Telephone Number	:	303-859-7630
Fax Number	:	720-398-3263

Authorized Official
Title or Position	:	LEAD PSYCHOTHERAPIST
Name	:	PERRI A CORVINO
Credential	:	LSW, MA, CAC I
Telephone Number	:	303-859-7630

Provider Enumeration Date	:	10/18/2012
Last Update Date	:	10/18/2012

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