Healthcare Provider Details

I. General information

NPI: 1134592256
Provider Name (Legal Business Name): INTEGRATION MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 65TH AVE STE C
GREELEY CO
80634-7965
US

IV. Provider business mailing address

1919 65TH AVE STE C
GREELEY CO
80634-7965
US

V. Phone/Fax

Practice location:
  • Phone: 970-590-1138
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number130627
License Number StateCO

VIII. Authorized Official

Name: SUSAN PONDER
Title or Position: OWNER
Credential:
Phone: 970-590-1138