Basic Information
| Provider Information | |||||||||
| NPI: | 1225579246 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALPINE LAKES COUNSELING CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILDFLOWER COUNSELING, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 CEYLON ST | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800115237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202991221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5460 WARD RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800021818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032199548 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOPPERSTAD | ||||||||
| AuthorizedOfficialFirstName: | CHELSIE | ||||||||
| AuthorizedOfficialMiddleName: | DANETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3032199548 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LSCW | ||||||||
| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CSW.09924087 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1386012706 | 05 | CO | MEDICAID | 9000164684 | 05 | CO | MEDICAID |