Basic Information
| Provider Information | |||||||||
| NPI: | 1164807210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEAK POTENTIAL BEHAVIOR & WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8324 CEDAR CHASE DR | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808174030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193311781 | ||||||||
| FaxNumber: | 7196388115 | ||||||||
| Practice Location | |||||||||
| Address1: | 8324 CEDAR CHASE DR | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808174030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193311781 | ||||||||
| FaxNumber: | 7196388115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7193311781 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-15649 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.