Healthcare Provider Details

I. General information

NPI: 1336873066
Provider Name (Legal Business Name): THE OTHER ROAD COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2022
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 GUNPARK DR STE 101
BOULDER CO
80301-7001
US

IV. Provider business mailing address

2004 W 15TH ST STE 2
LOVELAND CO
80538-3551
US

V. Phone/Fax

Practice location:
  • Phone: 970-217-2486
  • Fax:
Mailing address:
  • Phone: 720-446-6549
  • 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:

VIII. Authorized Official

Name: MALLORIE DANIELLE SMOLEN
Title or Position: OWNER
Credential:
Phone: 970-573-1655