Provider Demographics
NPI:1326556051
Name:COAL CREEK COUNSELING ASSOCIATES
Entity Type:Organization
Organization Name:COAL CREEK COUNSELING ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:720-233-5114
Mailing Address - Street 1:1036 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-1720
Mailing Address - Country:US
Mailing Address - Phone:720-233-5114
Mailing Address - Fax:
Practice Address - Street 1:357 MCCASLIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-2932
Practice Address - Country:US
Practice Address - Phone:720-233-5114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1538509153Medicaid