1558716563 NPI number — LUNA COUNSELING, LLC

Table of content: (NPI 1558716563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558716563 NPI number — LUNA COUNSELING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUNA COUNSELING, LLC
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:
1558716563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 964
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND LAKE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80447-0964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-531-6173
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79050 US HIGHWAY 40
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-531-6173
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THOMASSON
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
970-531-6173

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1655-00 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 1655-01 , 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)