Healthcare Provider Details

I. General information

NPI: 1548176126
Provider Name (Legal Business Name): AUTHENTIC SELF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 IRIS AVE STE 210
BOULDER CO
80301-1998
US

IV. Provider business mailing address

3333 IRIS AVE STE 210
BOULDER CO
80301-1998
US

V. Phone/Fax

Practice location:
  • Phone: 970-470-1240
  • Fax:
Mailing address:
  • Phone: 970-470-1240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARK DEWOLF
Title or Position: OWNER
Credential: MA, LPC, NCC
Phone: 970-470-1240