Provider Demographics
NPI:1043649429
Name:CHEYENNE MOUNTAIN COUNSELING & WELLNESS CENTER
Entity Type:Organization
Organization Name:CHEYENNE MOUNTAIN COUNSELING & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELODIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LMFT
Authorized Official - Phone:719-434-1088
Mailing Address - Street 1:108 E CHEYENNE RD STE 206
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-2535
Mailing Address - Country:US
Mailing Address - Phone:719-434-1088
Mailing Address - Fax:719-434-1166
Practice Address - Street 1:108 E CHEYENNE RD STE 206
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-2535
Practice Address - Country:US
Practice Address - Phone:719-434-1088
Practice Address - Fax:719-434-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6389101YP2500X
CO1069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty