Healthcare Provider Details

I. General information

NPI: 1063868263
Provider Name (Legal Business Name): A NEW LEAF THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 COLORADO AVE
PUEBLO CO
81004-2046
US

IV. Provider business mailing address

315 COLORADO AVE
PUEBLO CO
81004-2046
US

V. Phone/Fax

Practice location:
  • Phone: 719-948-7120
  • Fax: 719-289-7144
Mailing address:
  • Phone: 719-948-7120
  • Fax: 719-289-7144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPSY3290
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY3290
License Number StateCO

VIII. Authorized Official

Name: REGAN YOUNG
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LCSW, CACIII
Phone: 719-948-7120