Healthcare Provider Details

I. General information

NPI: 1457592644
Provider Name (Legal Business Name): THERAPEUTIC EXPERIENCES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 COUNTY ROAD 236
DURANGO CO
81301-8298
US

IV. Provider business mailing address

120 COUNTY ROAD 236
DURANGO CO
81301-8298
US

V. Phone/Fax

Practice location:
  • Phone: 970-749-0607
  • Fax: 970-247-2724
Mailing address:
  • Phone: 970-749-0607
  • Fax: 970-247-2724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateCO

VIII. Authorized Official

Name: MR. RONALD S. TYNER
Title or Position: PRESIDENT/CEO
Credential:
Phone: 970-749-0607