Healthcare Provider Details

I. General information

NPI: 1538793682
Provider Name (Legal Business Name): FAMILY THERAPY DTC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7430 E CALEY AVE STE 130E
CENTENNIAL CO
80111-6715
US

IV. Provider business mailing address

5905 ALTON ST
DENVER CO
80238-3995
US

V. Phone/Fax

Practice location:
  • Phone: 303-551-4615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ETHAN RIETEMA
Title or Position: OWNER
Credential: RP
Phone: 303-551-4615