=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558875591
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRONT RANGE TREATMENT CENTER, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2017
-----------------------------------------------------
Last Update Date | 11/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6075 S QUEBEC ST STE 200
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-4535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-390-6932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6075 S QUEBEC ST STE 200
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-4535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-390-6932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JENELL EFFINGER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 720-390-6932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY.0004384
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------