MEDICARE: SOUTHWEST COLORADO DBT LLC

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	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710631379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST COLORADO DBT LLC

Provider Business Mailing Address
First Line	:	1309 E 3RD AVE UNIT B-5
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-5255
Country	:	US
Telephone Number	:	414-315-0897
Fax Number	:

Provider Business Practice Location Address
First Line	:	1309 E 3RD AVE UNIT B-5
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-5255
Country	:	US
Telephone Number	:	414-315-0897
Fax Number	:	970-459-1141

Authorized Official
Title or Position	:	OWNER
Name	:	MS. LYNNE M ROSENBERG
Credential	:	LPC, LAC
Telephone Number	:	414-315-0897

Provider Enumeration Date	:	02/11/2022
Last Update Date	:	02/11/2022

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