1639676158 NPI number — CHRIS DE BRUIN LPC

Table of content: CHRIS DE BRUIN LPC (NPI 1639676158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639676158 NPI number — CHRIS DE BRUIN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE BRUIN
Provider First Name:
CHRIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

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:
1639676158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GRAND JUNCTION METRO TREATMENT CENTER
Provider Second Line Business Mailing Address:
1001 WELLINGTON AVE
Provider Business Mailing Address City Name:
GRAND JUNCTION
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-208-1130
Provider Business Mailing Address Fax Number:
970-208-1132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GRAND JUNCTION METRO TREATMENT CENTER
Provider Second Line Business Practice Location Address:
1001 WELLINGTON AVE
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-208-1130
Provider Business Practice Location Address Fax Number:
970-208-1132
Provider Enumeration Date:
04/11/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  617 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 3394 , 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)