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General NPI Number Information
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NPI Number | 1568668341
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Entity Type | Organization
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Legal Business Name | WESTERN SLOPE INNERCHANGE
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Dates
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Enumeration Date | 06/27/2007
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Last Update Date | 05/06/2016
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Provider Practice Location Address
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Address Line | 115 GRAND AVE STE 1
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City | DELTA
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State | CO
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Zip | 81416-2017
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Country | US
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Telephone | 970-874-0875
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Fax | 970-874-5443
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Provider Business Mailing Address
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Address Line | 115 GRAND AVE STE 1
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City | DELTA
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State | CO
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Zip | 81416-2017
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Country | US
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Telephone | 970-874-0875
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Fax | 970-874-5443
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRENDA K HOLLAND
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Credential | PHD
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Telephone | 970-874-0875
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 3712
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1490
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License Number State | CO
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