Healthcare Provider Details

I. General information

NPI: 1922492610
Provider Name (Legal Business Name): CHRISTOPHER LAWRENCE LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 28 3/4 RD
GRAND JUNCTION CO
81501-5016
US

IV. Provider business mailing address

715 HORIZON DR STE 225
GRAND JUNCTION CO
81506-8743
US

V. Phone/Fax

Practice location:
  • Phone: 970-241-6023
  • Fax:
Mailing address:
  • Phone: 970-683-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0000906
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: