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General NPI Number Information
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NPI Number | 1720282155
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Entity Type | Individual
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Provider Name | JUTHARAT MCCORMACK LPC, RN, CAC III
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Gender | Female
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Dates
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Enumeration Date | 06/11/2007
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Last Update Date | 07/16/2012
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Provider Practice Location Address
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Address Line | 2610 STOUT ST
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City | DENVER
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State | CO
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Zip | 80205-2941
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Country | US
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Telephone | 303-504-1200
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Fax |
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Provider Business Mailing Address
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Address Line | 2610 STOUT ST
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City | DENVER
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State | CO
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Zip | 80205-2941
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Country | US
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Telephone | 720-341-8694
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 7138
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6391
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 162465
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License Number State | CO
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