Healthcare Provider Details

I. General information

NPI: 1659422269
Provider Name (Legal Business Name): PHYLLIS KLAIF LCSW, CACIII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 IRIS AVE
BOULDER CO
80304-2226
US

IV. Provider business mailing address

1455 DIXON AVE
LAFAYETTE CO
80026-8879
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8500
  • Fax:
Mailing address:
  • Phone: 303-443-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6382
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number989162
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier59635568
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: