Provider Demographics
NPI:1376079095
Name:CENTERBOARD WELLNESS CENTER
Entity Type:Organization
Organization Name:CENTERBOARD WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CAC III, NCAC
Authorized Official - Phone:720-324-0008
Mailing Address - Street 1:14996 E GREENWOOD PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-3935
Mailing Address - Country:US
Mailing Address - Phone:720-324-0008
Mailing Address - Fax:
Practice Address - Street 1:4155 E JEWELL AVE STE 301
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-4507
Practice Address - Country:US
Practice Address - Phone:720-324-0008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1707-01251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health