Healthcare Provider Details

I. General information

NPI: 1699690099
Provider Name (Legal Business Name): MIRIAM ELYSE KREYKES STUDENT, HEALTH CARE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 TERRY ST
LONGMONT CO
80501-5930
US

IV. Provider business mailing address

3304 FOLSOM ST
BOULDER CO
80304-2404
US

V. Phone/Fax

Practice location:
  • Phone: 303-578-0527
  • Fax:
Mailing address:
  • Phone: 703-350-2449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: