Healthcare Provider Details

I. General information

NPI: 1093572349
Provider Name (Legal Business Name): OPTUM BEHAVIORAL CARE OF COLORADO, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1662 E CENTRE AVE
PORTAGE MI
49002-4496
US

IV. Provider business mailing address

11000 OPTUM CIR
EDEN PRAIRIE MN
55344-2503
US

V. Phone/Fax

Practice location:
  • Phone: 269-321-8564
  • Fax:
Mailing address:
  • Phone: 269-372-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LESLIE JOHNSON
Title or Position: CEO
Credential:
Phone: 704-506-6267