MEDICARE: CHRYSALIS CENTER FOR FAMILY GROWTH, 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	251S00000X	Community/Behavioral Health Agency	5217	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5217	OTHER	CO	LICENSE NUMBER

General Provider Information

NPI Number	:	1922236629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRYSALIS CENTER FOR FAMILY GROWTH, LLC

Provider Business Mailing Address
First Line	:	109 CAMERON DR BLDG A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3961
Country	:	US
Telephone Number	:	970-223-2054
Fax Number	:	970-223-5074

Provider Business Practice Location Address
First Line	:	109 CAMERON DR BLDG A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3961
Country	:	US
Telephone Number	:	970-223-2054
Fax Number	:	970-223-5074

Authorized Official
Title or Position	:	MEMBER, THERAPIST
Name	:	MS. SARAH HIGGINS
Credential	:	LPC, NCC
Telephone Number	:	970-223-2054

Provider Enumeration Date	:	07/01/2009
Last Update Date	:	07/01/2009

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