Provider Demographics
NPI:1114221678
Name:IDEA-THORNTON
Entity Type:Organization
Organization Name:IDEA-THORNTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARCELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PAIZ
Authorized Official - Suffix:
Authorized Official - Credentials:BS, CAC III
Authorized Official - Phone:303-477-8280
Mailing Address - Street 1:9150B N WASHINGTON ST # B
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-4305
Mailing Address - Country:US
Mailing Address - Phone:303-996-9966
Mailing Address - Fax:
Practice Address - Street 1:2560 W 29TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-3712
Practice Address - Country:US
Practice Address - Phone:303-477-8280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDEA FORUM, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COADAD 1322-03251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34958371Medicaid