Healthcare Provider Details

I. General information

NPI: 1073729828
Provider Name (Legal Business Name): RALPH S. DATEMA D MIN.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1564 SENTER AVE
BURLINGTON CO
80807-1645
US

IV. Provider business mailing address

6355 WARD RD UNIT 212
ARVADA CO
80004-3822
US

V. Phone/Fax

Practice location:
  • Phone: 303-974-0947
  • Fax:
Mailing address:
  • Phone: 303-974-0947
  • Fax: 720-242-6991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1441 76
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: