Healthcare Provider Details

I. General information

NPI: 1104698497
Provider Name (Legal Business Name): MICHELE RENEE HARVEY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 JET WING DR
COLORADO SPRINGS CO
80916-2332
US

IV. Provider business mailing address

1795 JET WING DR
COLORADO SPRINGS CO
80916-2332
US

V. Phone/Fax

Practice location:
  • Phone: 719-572-6100
  • Fax:
Mailing address:
  • Phone: 719-572-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT.0002835
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0002355
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: