Healthcare Provider Details

I. General information

NPI: 1558852566
Provider Name (Legal Business Name): SARAH BRESEKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 E STUART ST STE 101
FORT COLLINS CO
80525-1195
US

IV. Provider business mailing address

616 SYCAMORE ST
FORT COLLINS CO
80521-1938
US

V. Phone/Fax

Practice location:
  • Phone: 573-639-0112
  • Fax:
Mailing address:
  • Phone: 573-639-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC.0004992
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0004992
License Number StateCO

VIII. Authorized Official

Name: SARAH BRESEKE
Title or Position: OWNER
Credential: PHD
Phone: 573-639-0112