1528542149 NPI number — CENTER FOR POST TRAUMATIC GROWTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528542149 NPI number — CENTER FOR POST TRAUMATIC GROWTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR POST TRAUMATIC GROWTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528542149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5521 GRASSY RUN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLACERVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95667-9739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-743-7673
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11344 COLOMA RD STE 347
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLD RIVER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95670-4460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-743-7673
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KEENAN
Authorized Official First Name:
MELINDA
Authorized Official Middle Name:
JANE
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
720-743-7673

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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