Basic Information
| Provider Information | |||||||||
| NPI: | 1821636945 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DARLENE BRACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8335 MUSTANG PL | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809085024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709033588 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5540 N ACADEMY BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709033588 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2019 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | BRACE | ||||||||
| AuthorizedOfficialFirstName: | DARLENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9709033588 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW, LAC | ||||||||
| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | ACD.0000882 | 01 | CO | DORA | OTHER | CSW.00001998 | 01 | CO | DORA | OTHER |