Provider Demographics
NPI:1053061150
Name:DEVEREUX CLEO WALLACE
Entity Type:Organization
Organization Name:DEVEREUX CLEO WALLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY IMPROVEMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-438-2265
Mailing Address - Street 1:PO BOX 74292
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0002
Mailing Address - Country:US
Mailing Address - Phone:610-542-3064
Mailing Address - Fax:
Practice Address - Street 1:8405 CHURCH RANCH BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-3918
Practice Address - Country:US
Practice Address - Phone:610-542-3064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility