=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912269853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOETICUS ENTERPRISES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2012
-----------------------------------------------------
Last Update Date | 06/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 E 9TH AVE SUITE #290
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80203-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-399-9988
-----------------------------------------------------
Fax | 303-399-9977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 E 9TH AVE SUITE #290
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80203-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-399-9988
-----------------------------------------------------
Fax | 303-399-9977
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | PROF. JAMES RYAN KENNEDY
-----------------------------------------------------
Credential | LPC, LMFT, RN
-----------------------------------------------------
Telephone | 303-399-9988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number | 20041343635
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------