Basic Information
| Provider Information | |||||||||
| NPI: | 1194043760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | RAELYNN | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 28 3/4 RD | ||||||||
| Address2: | BLDG A | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815015016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706837107 | ||||||||
| FaxNumber: | 9702553963 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | RIFLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816508510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706253582 | ||||||||
| FaxNumber: | 9706259707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 11229 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 60835338 | 05 | CO | MEDICAID |