Healthcare Provider Details

I. General information

NPI: 1508338575
Provider Name (Legal Business Name): OUTSIDE REIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2018
Last Update Date: 12/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13576 COUNTY RD 1
FLORISSANT CO
80816-9001
US

IV. Provider business mailing address

13576 COUNTY RD 1
FLORISSANT CO
80816-9001
US

V. Phone/Fax

Practice location:
  • Phone: 719-235-7473
  • Fax: 719-748-0196
Mailing address:
  • Phone: 719-235-7473
  • Fax: 719-748-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. MONIQUE JULIA EKKER
Title or Position: OWNER/THERAPIST
Credential: LPC, LAC
Phone: 719-235-7473