Provider Demographics
NPI:1376885178
Name:MITTLESTADT, DONALD RY III (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:RY
Last Name:MITTLESTADT
Suffix:III
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GARDEN CTR STE 156
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1790
Mailing Address - Country:US
Mailing Address - Phone:303-578-8501
Mailing Address - Fax:
Practice Address - Street 1:80 GARDEN CTR STE 156
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1790
Practice Address - Country:US
Practice Address - Phone:303-578-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC13386101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional