=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871619494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC C BAILLY LPC, CAC III
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 01/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 BROADWAY
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80203-3421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-367-2900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2585 HOLLY ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80207-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-225-6158
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | 4447
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 2284
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------