MEDICARE: THEA WESSEL LPC, LAC, MAC, NCAAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	ACD.0000294	CO
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	MAC 507660	VA
3	101YP2500X	Professional Counselor	LPC.0011167	CO

General Provider Information

NPI Number	:	1396118857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEA WESSEL LPC, LAC, MAC, NCAAC

Provider Business Mailing Address
First Line	:	PO BOX 592
Second Line	:
City	:	BROOMFIELD
State	:	CO
Zip	:	80038-0592
Country	:	US
Telephone Number	:	781-990-8432
Fax Number	:

Provider Business Practice Location Address
First Line	:	1333 W 120TH AVE STE 222
Second Line	:
City	:	WESTMINSTER
State	:	CO
Zip	:	80234-2710
Country	:	US
Telephone Number	:	781-990-8432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2015
Last Update Date	:	01/21/2016

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