Provider Demographics
NPI:1093013526
Name:NEUROTHERAPY CENTER OF NORTHERN COLORADO, LLC
Entity Type:Organization
Organization Name:NEUROTHERAPY CENTER OF NORTHERN COLORADO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHAELE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:970-214-5712
Mailing Address - Street 1:503 REMINGTON ST STE 106
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3089
Mailing Address - Country:US
Mailing Address - Phone:970-214-5712
Mailing Address - Fax:970-315-0386
Practice Address - Street 1:503 REMINGTON ST STE 106
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3089
Practice Address - Country:US
Practice Address - Phone:970-214-5712
Practice Address - Fax:970-315-0386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO992151261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA100486OtherMEDICARE INDIVIDUAL PTAN
COCOA100485OtherMEDICARE GROUP PTAN
COCOA100486OtherMEDICARE INDIVIDUAL PTAN