Healthcare Provider Details

I. General information

NPI: 1821698812
Provider Name (Legal Business Name): ROCKY MOUNTAIN BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 CITADEL DR E STE 125
COLORADO SPRINGS CO
80909-5316
US

IV. Provider business mailing address

3239 INDEPENDENCE RD
CANON CITY CO
81212-9380
US

V. Phone/Fax

Practice location:
  • Phone: 719-275-7650
  • Fax: 719-275-4209
Mailing address:
  • Phone: 719-275-7650
  • Fax: 719-275-4209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: LOIS R PETERSEN-KELLEY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 719-275-7650