Healthcare Provider Details

I. General information

NPI: 1649180142
Provider Name (Legal Business Name): MYCELIUM PSYCHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 S SYCAMORE ST STE 200
LITTLETON CO
80120-1146
US

IV. Provider business mailing address

5575 S SYCAMORE ST STE 200
LITTLETON CO
80120-1146
US

V. Phone/Fax

Practice location:
  • Phone: 406-540-5950
  • Fax: 406-316-5991
Mailing address:
  • Phone: 406-540-5950
  • Fax: 406-316-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSE FISTER
Title or Position: OWNER
Credential: PHD
Phone: 406-540-5950