=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093013526
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROTHERAPY CENTER OF NORTHERN COLORADO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2011
-----------------------------------------------------
Last Update Date | 03/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 REMINGTON ST STE 106
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80524-3089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-214-5712
-----------------------------------------------------
Fax | 970-315-0386
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 503 REMINGTON ST STE 106
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80524-3089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-214-5712
-----------------------------------------------------
Fax | 970-315-0386
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER
-----------------------------------------------------
Name | MS. MICHAELE DAWN JOHNSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 970-214-5712
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 992151
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------