Healthcare Provider Details

I. General information

NPI: 1821479122
Provider Name (Legal Business Name): INDIVIDUAL PROVIDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4159 LOWELL BLVD
DENVER CO
80211-1658
US

IV. Provider business mailing address

2800 KALMIA AVE #A204
BOULDER CO
80301-1542
US

V. Phone/Fax

Practice location:
  • Phone: 303-458-7220
  • Fax:
Mailing address:
  • Phone: 970-618-6796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberNLC.0105326
License Number StateCO

VIII. Authorized Official

Name: ALICIA D LETO
Title or Position: THERAPIST
Credential: M.A.
Phone: 970-618-6796