Healthcare Provider Details

I. General information

NPI: 1831915958
Provider Name (Legal Business Name): LIFESPAN PSYCHIATRY OF COLORADO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 NORTH AVE
GRAND JUNCTION CO
81501-7513
US

IV. Provider business mailing address

2140 N 12TH ST
GRAND JUNCTION CO
81501-2916
US

V. Phone/Fax

Practice location:
  • Phone: 970-579-0003
  • Fax: 970-433-7671
Mailing address:
  • Phone: 970-579-0003
  • Fax: 970-433-7671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CARRIE SHAHBAHRAMI
Title or Position: OWNER
Credential:
Phone: 970-579-0003