Healthcare Provider Details

I. General information

NPI: 1720566250
Provider Name (Legal Business Name): ORIGINS PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8354 E NORTHFIELD BLVD UNIT 3700
DENVER CO
80238-3135
US

IV. Provider business mailing address

903 UINTA WAY
DENVER CO
80230-6885
US

V. Phone/Fax

Practice location:
  • Phone: 720-541-5854
  • Fax:
Mailing address:
  • Phone: 303-564-4830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY.0004530
License Number StateCO

VIII. Authorized Official

Name: YUKO KISHIMOTO
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 303-564-4830