Healthcare Provider Details

I. General information

NPI: 1487143046
Provider Name (Legal Business Name): KORISSA HOOVER BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 GRAND AVE
GLENWOOD SPRINGS CO
81601-4428
US

IV. Provider business mailing address

PO BOX 373
SNOWMASS CO
81654-0373
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-2583
  • Fax:
Mailing address:
  • Phone: 970-379-0955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC.0019047
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0001949
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: