Healthcare Provider Details

I. General information

NPI: 1356367197
Provider Name (Legal Business Name): KATHLEEN LAUREN EDD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4674 SNOW MESA DR STE 100
FORT COLLINS CO
80528
US

IV. Provider business mailing address

PO BOX 492
WINDSOR CO
80550
US

V. Phone/Fax

Practice location:
  • Phone: 970-221-1073
  • Fax: 970-221-9380
Mailing address:
  • Phone: 970-686-0970
  • Fax: 970-686-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1990
License Number StateCO

VIII. Authorized Official

Name: JESSICA L FREITAG
Title or Position: BILLING AGENT
Credential:
Phone: 970-686-0970