Provider Demographics
NPI:1164807210
Name:PEAK POTENTIAL BEHAVIOR & WELLNESS LLC
Entity Type:Organization
Organization Name:PEAK POTENTIAL BEHAVIOR & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:719-331-1781
Mailing Address - Street 1:8324 CEDAR CHASE DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4030
Mailing Address - Country:US
Mailing Address - Phone:719-331-1781
Mailing Address - Fax:719-638-8115
Practice Address - Street 1:8324 CEDAR CHASE DR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-4030
Practice Address - Country:US
Practice Address - Phone:719-331-1781
Practice Address - Fax:719-638-8115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-14-15649103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty