1932261617 NPI number — CANON CITY COUNSELING & PSYCHOTHERAPY SERVICES

Table of content: (NPI 1932261617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932261617 NPI number — CANON CITY COUNSELING & PSYCHOTHERAPY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANON CITY COUNSELING & PSYCHOTHERAPY SERVICES
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:
1932261617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 LATIGO LN
Provider Second Line Business Mailing Address:
SUITE E-2
Provider Business Mailing Address City Name:
CANON CITY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81212-8112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-275-4442
Provider Business Mailing Address Fax Number:
719-275-4442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 LATIGO LN
Provider Second Line Business Practice Location Address:
SUITE E-2
Provider Business Practice Location Address City Name:
CANON CITY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81212-8112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-275-4442
Provider Business Practice Location Address Fax Number:
719-275-4442
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORLOCK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
719-275-4442

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  992271 , 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: 992271 . This is a "LCSW LICENSE NUMBER" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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