Healthcare Provider Details

I. General information

NPI: 1396961819
Provider Name (Legal Business Name): LANETTE CID LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 INDEPENDENCE RD
CANON CITY CO
81212-9380
US

IV. Provider business mailing address

3225 INDEPENDENCE RD
CANON CITY CO
81212-9380
US

V. Phone/Fax

Practice location:
  • Phone: 719-275-2351
  • Fax: 719-269-9386
Mailing address:
  • Phone: 719-275-2351
  • Fax: 719-269-9386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0003316
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: