Healthcare Provider Details

I. General information

NPI: 1891365813
Provider Name (Legal Business Name): IAN KANDER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 MIDLAND AVE STE 15B
BASALT CO
81621-8119
US

IV. Provider business mailing address

PO BOX 1115
BASALT CO
81621-1115
US

V. Phone/Fax

Practice location:
  • Phone: 970-925-5858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0017268
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: