=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194541201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KYMBERLY MAESTAS, LPC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2024
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 MAIN ST STE 201
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81501-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-549-2849
-----------------------------------------------------
Fax | 970-549-1400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 MAIN ST STE 201
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81501-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-549-2849
-----------------------------------------------------
Fax | 970-549-1400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH THERAPIST
-----------------------------------------------------
Name | KYMBERLY MAESTAS-CANNON
-----------------------------------------------------
Credential | MA, LPC, CAS, NCC
-----------------------------------------------------
Telephone | 970-623-0512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------