Healthcare Provider Details

I. General information

NPI: 1023066164
Provider Name (Legal Business Name): DOUGLAS ERIC HANSHAW MS, CAC III
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W. COLORADO AVE. SUITE 225
TELLURIDE CO
81435
US

IV. Provider business mailing address

751 CR 14A PO BOX 1407
OURAY CO
81427-1407
US

V. Phone/Fax

Practice location:
  • Phone: 970-596-1412
  • Fax: 970-325-0200
Mailing address:
  • Phone: 970-596-1412
  • Fax: 970-325-0200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6365
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: