MEDICARE: CHERYL KIMPLE TRAVIS MAED,

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	6214	CO
2	101YM0800X	Mental Health Counselor	10243	CO

General Provider Information

NPI Number	:	1518116318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL KIMPLE TRAVIS MAED,

Provider Business Mailing Address
First Line	:	825 E. SPEER BLVD #14
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80218-8118
Country	:	US
Telephone Number	:	303-638-9911
Fax Number	:	303-543-0365

Provider Business Practice Location Address
First Line	:	825 E SPEER BLVD # 14
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80218-3719
Country	:	US
Telephone Number	:	303-638-9911
Fax Number	:	303-543-0365

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

Provider Enumeration Date	:	09/16/2008
Last Update Date	:	05/24/2016

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