MEDICARE: ROXANNE UPSHAW, INC.

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1710473616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROXANNE UPSHAW, INC.

Provider Business Mailing Address
First Line	:	PO BOX 622
Second Line	:
City	:	MANITOU SPRINGS
State	:	CO
Zip	:	80829-0622
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	441 MANITOU AVE STE 201
Second Line	:
City	:	MANITOU SPRINGS
State	:	CO
Zip	:	80829-2334
Country	:	US
Telephone Number	:	719-963-6487
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROXANNE UPSHAW
Credential	:	PHD, LPC
Telephone Number	:	719-963-6487

Provider Enumeration Date	:	07/03/2018
Last Update Date	:	07/03/2018

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