Healthcare Provider Details

I. General information

NPI: 1134719305
Provider Name (Legal Business Name): CALLIE GUMMOW MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 S POTOMAC ST
AURORA CO
80012-4535
US

IV. Provider business mailing address

1935 WABASH ST
DENVER CO
80220-2148
US

V. Phone/Fax

Practice location:
  • Phone: 970-363-4563
  • Fax:
Mailing address:
  • Phone: 602-502-9824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC.0016799
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0016799
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: