Basic Information
Provider Information | |||||||||
NPI: | 1245849736 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDREN'S WELLNESS CENTER OF COLORADO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 2220 CURVE PLAZA | ||||||||
Address2: | SUITE 203 | ||||||||
City: | STEAMBOAT SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 80487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7206627862 | ||||||||
FaxNumber: | 7205732862 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2020 | ||||||||
LastUpdateDate: | 08/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARCIA | ||||||||
AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
AuthorizedOfficialMiddleName: | WERNER | ||||||||
AuthorizedOfficialTitleorPosition: | COOWNER | ||||||||
AuthorizedOfficialTelephone: | 7206627862 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 60125080 | 05 | CO |   | MEDICAID | 60155080 | 05 | CO |   | MEDICAID |