Healthcare Provider Details

I. General information

NPI: 1982925897
Provider Name (Legal Business Name): LUNA COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 01/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 EAST AGATE AVE.
GRANBY CO
80446
US

IV. Provider business mailing address

PO BOX 964
GRAND LAKE CO
80447-0964
US

V. Phone/Fax

Practice location:
  • Phone: 970-531-6173
  • Fax: 970-887-2293
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1655-00
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number165500
License Number StateCO

VIII. Authorized Official

Name: MR. ANDREW THOMASSON
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 970-531-6173