=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114448347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLORADO COUPLES CLINIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 WADSWORTH BLVD STE 308
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80214-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-956-7622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 WADSWORTH BLVD STE 308
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80214-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-956-7622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANGELA TSIATSOS PHILLIPS
-----------------------------------------------------
Credential | MA, LPC, NCC, ACS
-----------------------------------------------------
Telephone | 303-956-7622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 11335
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------