=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396118857
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEA WESSEL LPC, LAC, MAC, NCAAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2015
-----------------------------------------------------
Last Update Date | 01/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1333 W 120TH AVE STE 222
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80234-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-990-8432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 592
-----------------------------------------------------
City | BROOMFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80038-0592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-990-8432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | ACD.0000294
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | MAC 507660
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC.0011167
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------