=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215158407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOURCE COUNSELING AND CONTRACTING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 03/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9255 W ALAMEDA AVE UNIT E
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80226-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-994-0673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9255 W ALAMEDA AVE UNIT E
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80226-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-994-0673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAROLYN ANNE VACCARELLA
-----------------------------------------------------
Credential | MA LPC
-----------------------------------------------------
Telephone | 303-994-0673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 4255
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4255
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------