=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396267639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE LIFE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2017
-----------------------------------------------------
Last Update Date | 07/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3773 E CHERRY CREEK NORTH DR STE 575
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80209-3825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-733-9519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 S GRANT ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80209-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-733-9519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND PROVIDER
-----------------------------------------------------
Name | ERICA VIGGIANO
-----------------------------------------------------
Credential | LCSW, RDN, C-IAYT
-----------------------------------------------------
Telephone | 303-733-9519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 992073
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------