Basic Information
| Provider Information | |||||||||
| NPI: | 1992170740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIMARCELLA | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4851 INDEPENDENCE ST | ||||||||
| Address2: | SUTIE 200 | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034250300 | ||||||||
| FaxNumber: | 3034325071 | ||||||||
| Practice Location | |||||||||
| Address1: | 4851 INDEPENDENCE ST | ||||||||
| Address2: | SUTIE 200 | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034250300 | ||||||||
| FaxNumber: | 3034325071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2015 | ||||||||
| LastUpdateDate: | 04/22/2019 | ||||||||
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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 | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 0015012 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0015012 | 05 | CO | MEDICAID |