=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831534247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERPATH COUNSELING COLORADO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2013
-----------------------------------------------------
Last Update Date | 04/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5255 RONALD REAGAN BLVD SUITE 220
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80534-6435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-370-7284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5255 RONALD REAGAN BLVD SUITE 220
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80534-6435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-370-7284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | ALEXANDER JOSEPH MICHAUD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-370-7284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 013337
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------