Healthcare Provider Details

I. General information

NPI: 1295392868
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF COLORADO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4863 N NEVADA AVE STE 321
COLORADO SPRINGS CO
80918-3951
US

IV. Provider business mailing address

4863 N NEVADA AVE STE 321
COLORADO SPRINGS CO
80918-3951
US

V. Phone/Fax

Practice location:
  • Phone: 719-255-8002
  • Fax: 719-255-8006
Mailing address:
  • Phone: 719-255-8002
  • Fax: 719-255-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MAGDALENE LIM
Title or Position: DIRECTOR
Credential: PSYD
Phone: 719-255-8002