1851032643 NPI number — COLORADO PSYCH CLINIC LLC

Table of content: (NPI 1851032643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851032643 NPI number — COLORADO PSYCH CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO PSYCH CLINIC 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:
1851032643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/03/2024
NPI Reactivation Date:
04/19/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 N NEVADA AVE STE 1E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80903-1075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-726-1077
Provider Business Mailing Address Fax Number:
719-960-2933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 N NEVADA AVE STE 1E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80903-1075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-726-1077
Provider Business Practice Location Address Fax Number:
719-960-2933
Provider Enumeration Date:
04/05/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-726-1077

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9000204851 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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