Healthcare Provider Details

I. General information

NPI: 1447883566
Provider Name (Legal Business Name): MOUNT TABOR COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5945 WARD RD STE 100
ARVADA CO
80004-3901
US

IV. Provider business mailing address

12500 W 58TH AVE UNIT 211
ARVADA CO
80002-1104
US

V. Phone/Fax

Practice location:
  • Phone: 303-422-1567
  • Fax:
Mailing address:
  • Phone: 303-422-1567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN BALKE
Title or Position: PRESIDENT
Credential:
Phone: 303-422-1567