=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689597700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING GROVE INTEGRATIVE BEHAVIORAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2026
-----------------------------------------------------
Last Update Date | 08/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5655 S YOSEMITE ST STE 201
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-3220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-203-6266
-----------------------------------------------------
Fax | 720-528-7939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5655 S YOSEMITE ST STE 201
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-3220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-203-6266
-----------------------------------------------------
Fax | 720-528-7939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL & PRESCRIBING PSYCHOLOGIST
-----------------------------------------------------
Name | DR. DIEM PHAN
-----------------------------------------------------
Credential | PHD, MSCP
-----------------------------------------------------
Telephone | 720-203-6266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP0016X
-----------------------------------------------------
Taxonomy Name | Prescribing (Medical) Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------