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NPI Code Detail

MEDICARE: ORIGINS PSYCHOLOGICAL SERVICES, LLC

MEDICARE: ORIGINS PSYCHOLOGICAL SERVICES, 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
1103TC1900XCounseling PsychologistPSY.0004530CO

General Provider Information

NPI Number : 1720566250
Entity Type Code : Organization
Provider Name (Legal Business Name) : ORIGINS PSYCHOLOGICAL SERVICES, LLC
Provider Business Mailing Address
First Line : 903 UINTA WAY
Second Line :
City : DENVER
State : CO
Zip : 80230-6885
Country : US
Telephone Number : 303-564-4830
Fax Number :
Provider Business Practice Location Address
First Line : 8354 E NORTHFIELD BLVD UNIT 3700
Second Line :
City : DENVER
State : CO
Zip : 80238-3135
Country : US
Telephone Number : 720-541-5854
Fax Number :
Authorized Official
Title or Position : PSYCHOLOGIST
Name : YUKO KISHIMOTO
Credential : PHD
Telephone Number : 303-564-4830
Provider Enumeration Date : 08/06/2018
Last Update Date : 08/06/2018

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