Healthcare Provider Details

I. General information

NPI: 1912725961
Provider Name (Legal Business Name): UNHARNESSED POTENTIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8655 KANE RD
FOUNTAIN CO
80817-3339
US

IV. Provider business mailing address

8655 KANE RD
FOUNTAIN CO
80817-3339
US

V. Phone/Fax

Practice location:
  • Phone: 913-269-6120
  • Fax: 719-434-8867
Mailing address:
  • Phone: 913-269-6120
  • Fax: 719-434-8867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ERIN M SLIVKA
Title or Position: OWNER
Credential:
Phone: 913-269-6120