Provider Demographics
NPI:1235458597
Name:RESILIA NEUROTHERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:RESILIA NEUROTHERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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, MBA
Authorized Official - Phone:970-350-0135
Mailing Address - Street 1:503 REMINGTON ST STE 104
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:970-530-0135
Mailing Address - Fax:970-315-0386
Practice Address - Street 1:503 REMINGTON ST STE 104
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:970-530-0135
Practice Address - Fax:970-315-0386
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESILIA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22494261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA82718Medicare UPIN