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General NPI Number Information
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NPI Number | 1558852566
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Entity Type | Organization
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Legal Business Name | SARAH BRESEKE
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Dates
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Enumeration Date | 05/24/2018
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Last Update Date | 05/24/2018
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Provider Practice Location Address
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Address Line | 1136 E STUART ST STE 101
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City | FORT COLLINS
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State | CO
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Zip | 80525-1195
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Country | US
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Telephone | 573-639-0112
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Fax |
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Provider Business Mailing Address
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Address Line | 616 SYCAMORE ST
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City | FORT COLLINS
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State | CO
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Zip | 80521-1938
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Country | US
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Telephone | 573-639-0112
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SARAH BRESEKE
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Credential | PHD
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Telephone | 573-639-0112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0004992
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | LPC.0004992
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License Number State | CO
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