Healthcare Provider Details

I. General information

NPI: 1033021837
Provider Name (Legal Business Name): IMARI ASHANTI KETURAH ABDULLAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 BOARDWALK DR STE 490
FORT COLLINS CO
80525-3040
US

IV. Provider business mailing address

155 BOARDWALK DR STE 490
FORT COLLINS CO
80525-3040
US

V. Phone/Fax

Practice location:
  • Phone: 720-339-2050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-469305
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: