=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992392997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEST LIFE COLORADO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2020
-----------------------------------------------------
Last Update Date | 07/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 UNION BLVD STE 200
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-1831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-201-2389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 CENTRAL AVE STE 800
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33701-3984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-201-2389
-----------------------------------------------------
Fax | 855-224-4326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JENNIFER PHELPS
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 727-201-2223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------