Healthcare Provider Details

I. General information

NPI: 1306415187
Provider Name (Legal Business Name): DUSTIN RYDER HILES LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DUSTIN HILES LPC

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ARAPAHOE AVE STE 9
BOULDER CO
80302-5854
US

IV. Provider business mailing address

1905 15TH ST UNIT 2091
BOULDER CO
80306-8483
US

V. Phone/Fax

Practice location:
  • Phone: 970-614-8765
  • Fax:
Mailing address:
  • Phone: 970-614-8765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0017257
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0017257
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: