1750812889 NPI number — AUTUMN TREE THERAPY

Table of content: (NPI 1750812889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750812889 NPI number — AUTUMN TREE THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUTUMN TREE THERAPY
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:
1750812889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2935 BASELINE RD
Provider Second Line Business Mailing Address:
STE. 302
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80303-2366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-875-2364
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2935 BASELINE RD
Provider Second Line Business Practice Location Address:
STE. 302
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80303-2366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-875-2364
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN-FOX
Authorized Official First Name:
CARLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICIAN/OWNER
Authorized Official Telephone Number:
303-875-2364

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  727 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 54105081 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com