Healthcare Provider Details

I. General information

NPI: 1790521482
Provider Name (Legal Business Name): KRYSTAL ELLISON BA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 KEN PRATT BLVD STE 300J
LONGMONT CO
80501-7078
US

IV. Provider business mailing address

1500 N GRANT ST STE R
DENVER CO
80203-1859
US

V. Phone/Fax

Practice location:
  • Phone: 303-578-0361
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0023492
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: