Healthcare Provider Details

I. General information

NPI: 1346600277
Provider Name (Legal Business Name): BOULDER ADDICTIONS COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 30TH ST SUITE 207
BOULDER CO
80301-1088
US

IV. Provider business mailing address

1800 30TH ST SUITE 207
BOULDER CO
80301-1088
US

V. Phone/Fax

Practice location:
  • Phone: 424-646-3385
  • Fax:
Mailing address:
  • Phone: 424-646-3385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC.0012761
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberACD.0000346
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name: THOMAS MIDGLEY
Title or Position: CLINICAL DIRECTOR
Credential: MA, LAC, LPC
Phone: 720-989-4987