=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689823668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOTHERAPY AND CARE MANAGEMENT ON THE GO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2008
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12954 W ILIFF AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-4336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-204-6635
-----------------------------------------------------
Fax | 303-504-6410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12954 W ILIFF AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-4336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-204-6635
-----------------------------------------------------
Fax | 303-504-6410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LEANN GRACE HANSEN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 303-204-6635
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Pharmacology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------