Healthcare Provider Details

I. General information

NPI: 1124721691
Provider Name (Legal Business Name): THE EMERALD COUCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 W 26TH AVE STE 465C
DENVER CO
80211-5315
US

IV. Provider business mailing address

2460 W 26TH AVE STE 465C
DENVER CO
80211-5315
US

V. Phone/Fax

Practice location:
  • Phone: 720-707-1383
  • Fax:
Mailing address:
  • Phone: 720-707-1383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MITRA LYNN LEBASTCHI
Title or Position: OWNER AND DIRECTOR
Credential: PSYD
Phone: 720-707-1383