Healthcare Provider Details

I. General information

NPI: 1053868687
Provider Name (Legal Business Name): WHOLE CONNECTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ARAPAHOE AVE STE 9
BOULDER CO
80302-5854
US

IV. Provider business mailing address

100 ARAPAHOE AVE STE 12
BOULDER CO
80302-5815
US

V. Phone/Fax

Practice location:
  • Phone: 720-316-7774
  • Fax:
Mailing address:
  • Phone: 720-316-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number#CSW.09923711
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
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
Identifier870736
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: PHILLIP HORNER
Title or Position: LCSW
Credential:
Phone: 720-316-7774