Provider Demographics
NPI:1033978853
Name:PROVIDENCE NETWORK
Entity Type:Organization
Organization Name:PROVIDENCE NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:KUYKENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-860-8484
Mailing Address - Street 1:801 N LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-3114
Mailing Address - Country:US
Mailing Address - Phone:303-744-3986
Mailing Address - Fax:
Practice Address - Street 1:2514 CHAMPA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2643
Practice Address - Country:US
Practice Address - Phone:303-744-3986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty