Healthcare Provider Details

I. General information

NPI: 1194043760
Provider Name (Legal Business Name): RAELYNN PEDERSEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 AIRPORT RD
RIFLE CO
81650-8510
US

IV. Provider business mailing address

515 28 3/4 RD BLDG A
GRAND JUNCTION CO
81501-5016
US

V. Phone/Fax

Practice location:
  • Phone: 970-625-3582
  • Fax: 970-625-9707
Mailing address:
  • Phone: 970-683-7107
  • Fax: 970-255-3963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11229
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: