Basic Information
| Provider Information | |||||||||
| NPI: | 1396082053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COULTER | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5984 S PRINCE ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801202083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033889749 | ||||||||
| FaxNumber: | 3038890838 | ||||||||
| Practice Location | |||||||||
| Address1: | 5984 S PRINCE ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801202083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033889749 | ||||||||
| FaxNumber: | 3038890838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2013 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6044 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 3597 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.