Healthcare Provider Details

I. General information

NPI: 1982853073
Provider Name (Legal Business Name): ROCKY MOUNTAIN MEMORY CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 LAPORTE AVE
FORT COLLINS CO
80521-2522
US

IV. Provider business mailing address

2801 REMINGTON ST STE 1
FORT COLLINS CO
80525-2566
US

V. Phone/Fax

Practice location:
  • Phone: 970-221-1073
  • Fax:
Mailing address:
  • Phone: 970-221-1073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1024531
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1990
License Number StateCO

VIII. Authorized Official

Name: DR. KATHLEEN A LAUREN
Title or Position: CLINICAL DIRECTOR
Credential: ED.D.
Phone: 970-221-1073