Healthcare Provider Details

I. General information

NPI: 1619473386
Provider Name (Legal Business Name): KERRY DUANE HAMMACK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2277 N MOUNTAIN ESTATES RD
FLORISSANT CO
80816-8957
US

IV. Provider business mailing address

2277 N MOUNTAIN ESTATES RD
FLORISSANT CO
80816-8957
US

V. Phone/Fax

Practice location:
  • Phone: 719-208-7700
  • Fax:
Mailing address:
  • Phone: 719-208-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0011746
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: