Healthcare Provider Details

I. General information

NPI: 1417144700
Provider Name (Legal Business Name): BONNIE MUCKLOW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 S PARKER RD STE 100
DENVER CO
80234
US

IV. Provider business mailing address

1191 S PARKER RD STE 100
DENVER CO
80234
US

V. Phone/Fax

Practice location:
  • Phone: 720-488-3822
  • Fax: 303-798-3883
Mailing address:
  • Phone: 720-488-3822
  • Fax: 303-798-3883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number114
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number116
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number980
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number149
License Number StateCO

VIII. Authorized Official

Name: BONNIE MUCKLOW
Title or Position: OWNER
Credential: LPC
Phone: 720-898-8711