Basic Information
| Provider Information | |||||||||
| NPI: | 1023466893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S WELLNESS CENTER OF COLORADO, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12150 E BRIARWOOD AVE UNIT 202 | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801126755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206627862 | ||||||||
| FaxNumber: | 7205732862 | ||||||||
| Practice Location | |||||||||
| Address1: | 12150 E BRIARWOOD AVE UNIT 202 | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801126755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206627862 | ||||||||
| FaxNumber: | 7205732862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2016 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO-OWNER & PSYCHOTHERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7206627862 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA, LPC | ||||||||
| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6486 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1023466893 | 05 | CO | MEDICAID | 60125080 | 05 | CO | MEDICAID |