Healthcare Provider Details

I. General information

NPI: 1962476408
Provider Name (Legal Business Name): DAVID PHILLIPS CANTRELL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S COLLEGE AVE SUITE 200
FORT COLLINS CO
80524-3184
US

IV. Provider business mailing address

112 S COLLEGE AVE SUITE 200
FORT COLLINS CO
80524-3184
US

V. Phone/Fax

Practice location:
  • Phone: 970-407-2959
  • Fax: 970-482-7300
Mailing address:
  • Phone: 970-407-2959
  • Fax: 970-482-7300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number0219590
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: