Provider Demographics
NPI:1194043760
Name:PEDERSEN, RAELYNN (LPC)
Entity Type:Individual
Prefix:
First Name:RAELYNN
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 28 3/4 RD
Mailing Address - Street 2:BLDG A
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-5016
Mailing Address - Country:US
Mailing Address - Phone:970-683-7107
Mailing Address - Fax:970-255-3963
Practice Address - Street 1:501 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-8510
Practice Address - Country:US
Practice Address - Phone:970-625-3582
Practice Address - Fax:970-625-9707
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11229101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60835338Medicaid