Healthcare Provider Details

I. General information

NPI: 1184723660
Provider Name (Legal Business Name): DEVEREUX CLEO WALLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 CHURCH RANCH BLVD
WESTMINSTER CO
80021-3918
US

IV. Provider business mailing address

8405 CHURCH RANCH BLVD
WESTMINSTER CO
80021-3918
US

V. Phone/Fax

Practice location:
  • Phone: 303-466-7391
  • Fax:
Mailing address:
  • Phone: 303-466-7391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number39794
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number39794
License Number StateCO

VIII. Authorized Official

Name: BONNIE WRIGHT
Title or Position: QUALITY IMPROVEMENT DIRECTOR
Credential:
Phone: 303-438-2265