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General NPI Number Information
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NPI Number | 1154776946
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Entity Type | Organization
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Legal Business Name | MAMA BIRD WELLNESS, LLC
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Dates
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Enumeration Date | 04/28/2016
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Last Update Date | 04/28/2016
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Provider Practice Location Address
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Address Line | 424 E SIMPSON ST
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City | LAFAYETTE
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State | CO
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Zip | 80026-2328
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Country | US
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Telephone | 303-835-3552
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Fax |
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Provider Business Mailing Address
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Address Line | 2013 E 167TH WAY
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City | THORNTON
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State | CO
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Zip | 80602-7650
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Country | US
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Telephone | 303-835-3552
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA HANLIN
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Credential | LCSW
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Telephone | 303-835-3552
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | CSW.00002154
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License Number State | CO
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