Healthcare Provider Details

I. General information

NPI: 1023854924
Provider Name (Legal Business Name): INNER PATH THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 BROADWAY STE 314C
BOULDER CO
80302-5233
US

IV. Provider business mailing address

1942 BROADWAY STE 314C
BOULDER CO
80302-5233
US

V. Phone/Fax

Practice location:
  • Phone: 720-213-8717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1841806502
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: CAROLINA SANTOS BRACCO
Title or Position: THERAPIST
Credential:
Phone: 720-213-8717