Healthcare Provider Details

I. General information

NPI: 1366066110
Provider Name (Legal Business Name): DR. IONE RENEE LAFATA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

31 SPRUCE LAKE DR
DIVIDE CO
80814-9757
US

IV. Provider business mailing address

31 SPRUCE LAKE DR
DIVIDE CO
80814-9757
US

V. Phone/Fax

Practice location:
  • Phone: 719-900-8894
  • Fax:
Mailing address:
  • Phone: 719-900-8894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberNLC.0111058
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberNLC.0111058
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberNLC.0111058
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMFT0003
License Number StateGU
# 5
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberNLC.0111058
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: