MEDICARE: ROCKY MOUNTAIN MEMORY CENTER PLLC

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	225X00000X	Occupational Therapist	1024531	CO
2	103G00000X	Clinical Neuropsychologist	1990	CO

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

General Provider Information

NPI Number	:	1982853073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKY MOUNTAIN MEMORY CENTER PLLC

Provider Business Mailing Address
First Line	:	2801 REMINGTON ST STE 1
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2566
Country	:	US
Telephone Number	:	970-221-1073
Fax Number	:

Provider Business Practice Location Address
First Line	:	951 LAPORTE AVE
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-2522
Country	:	US
Telephone Number	:	970-221-1073
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. KATHLEEN A LAUREN
Credential	:	ED.D.
Telephone Number	:	970-221-1073

Provider Enumeration Date	:	09/12/2008
Last Update Date	:	05/24/2012

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