Healthcare Provider Details

I. General information

NPI: 1851874515
Provider Name (Legal Business Name): ANTLERS CREEK COUNSELING CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12106 RIO SECCO RD
PEYTON CO
80831-4032
US

IV. Provider business mailing address

12106 RIO SECCO RD
PEYTON CO
80831-4032
US

V. Phone/Fax

Practice location:
  • Phone: 719-220-8662
  • Fax:
Mailing address:
  • Phone: 719-394-8797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09923654
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1911930832
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: MRS. RENEE M MARTINEZ-EPPERSON
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW, CACII
Phone: 719-394-8797