Basic Information
| Provider Information | |||||||||
| NPI: | 1841469608 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARBOR HOUSE COLLABORATIVE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HARBOR HOUSE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1710 E. PIKES PEAK AVENUE, | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194735557 | ||||||||
| FaxNumber: | 7194736442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 E. PIKES PEAK AVENUE, | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194735557 | ||||||||
| FaxNumber: | 7194736442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 02/23/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURNS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7194735557 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 1614-01 | CO | N | Agencies | Case Management | 251S00000X | 1614-01 | CO | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 14675773 | 05 | CO | MEDICAID | 1614-01 | 01 | CO | ALCOHOL AND DRUG ABUSE DI | OTHER |