Provider Demographics
NPI:1326615501
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/ CLINCAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA
Authorized Official - Phone:940-368-7105
Mailing Address - Street 1:5350 N ACADEMY BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4055
Mailing Address - Country:US
Mailing Address - Phone:940-368-7105
Mailing Address - Fax:
Practice Address - Street 1:5350 N ACADEMY BLVD STE 102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4055
Practice Address - Country:US
Practice Address - Phone:940-368-7105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty