Healthcare Provider Details

I. General information

NPI: 1831005644
Provider Name (Legal Business Name): DENISE JANE ITULE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 S SHIELDS STREET SUITE 1K #815
FORT COLLINS CO
80526-4134
US

IV. Provider business mailing address

2519 S SHIELDS ST STE 1K
FORT COLLINS CO
80526-1855
US

V. Phone/Fax

Practice location:
  • Phone: 970-481-9648
  • Fax:
Mailing address:
  • Phone: 970-481-9648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0003037
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC.0021826
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: