Healthcare Provider Details

I. General information

NPI: 1992347959
Provider Name (Legal Business Name): MY THERAPY PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11095 MCKISSICK RD
PEYTON CO
80831-8326
US

IV. Provider business mailing address

11095 MCKISSICK RD
PEYTON CO
80831-8326
US

V. Phone/Fax

Practice location:
  • Phone: 719-310-9792
  • Fax:
Mailing address:
  • Phone: 719-310-9792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY SINCLAIR
Title or Position: CEO
Credential: LPCC, LAC
Phone: 719-310-9792