=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811244296
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY NEIL CYPERT II M.ED., LPC, LAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2012
-----------------------------------------------------
Last Update Date | 04/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 S BELLAIRE ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-786-4460
-----------------------------------------------------
Fax | 806-786-4460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 130
-----------------------------------------------------
City | BROOMFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80038-0130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-786-4460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 11483
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 68694
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC.0012269
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | ACD.0000538
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------