Provider Demographics
NPI:1043605009
Name:FOUNTAINHEAD PSYCHOLOGY GROUP, LLC
Entity Type:Organization
Organization Name:FOUNTAINHEAD PSYCHOLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:303-818-5540
Mailing Address - Street 1:641 YORK ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-3745
Mailing Address - Country:US
Mailing Address - Phone:303-818-5540
Mailing Address - Fax:
Practice Address - Street 1:1828 N CLARKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1030
Practice Address - Country:US
Practice Address - Phone:303-818-5540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2526103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty