Provider Demographics
NPI:1174256465
Name:PEDIATRIC & FAMILY PSYCHIATRY LLC
Entity Type:Organization
Organization Name:PEDIATRIC & FAMILY PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:719-407-3312
Mailing Address - Street 1:4740 FLINTRIDGE DR STE 220O
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4273
Mailing Address - Country:US
Mailing Address - Phone:719-407-3312
Mailing Address - Fax:
Practice Address - Street 1:4740 FLINTRIDGE DR STE 220O
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4273
Practice Address - Country:US
Practice Address - Phone:719-407-3312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-05
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000176721Medicaid
CO06D2265433OtherCLIA