Healthcare Provider Details

I. General information

NPI: 1003609595
Provider Name (Legal Business Name): GROUNDED LIGHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 SOUTH HOWES STREET
FORT COLLINS CO
80521
US

IV. Provider business mailing address

2519 S SHIELDS STREET STE 1K PMB 1063
FORT COLLINS CO
80526-1855
US

V. Phone/Fax

Practice location:
  • Phone: 402-889-3527
  • Fax:
Mailing address:
  • Phone: 402-889-3527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LISA PERMAR
Title or Position: OWNER/PRACTICE MANAGER
Credential:
Phone: 402-889-3527