Basic Information
Provider Information | |||||||||
NPI: | 1578182820 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEGASUS EQUINE THERAPY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2233 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MONTROSE | ||||||||
State: | CO | ||||||||
PostalCode: | 814013831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9707650811 | ||||||||
FaxNumber: | 9704978410 | ||||||||
Practice Location | |||||||||
Address1: | 121 N PARK AVE | ||||||||
Address2: |   | ||||||||
City: | MONTROSE | ||||||||
State: | CO | ||||||||
PostalCode: | 814013768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9705962493 | ||||||||
FaxNumber: | 9702491576 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/15/2020 | ||||||||
LastUpdateDate: | 04/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALEXANDER | ||||||||
AuthorizedOfficialFirstName: | KAY | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9702406792 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PEGASUS EQUIINE THERAPY LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: | 04/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.