Provider Demographics
NPI:1497007199
Name:BOTHWELL, DEBORAH D (CAC III)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:D
Last Name:BOTHWELL
Suffix:
Gender:F
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CRESTRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3934
Mailing Address - Country:US
Mailing Address - Phone:970-494-9761
Mailing Address - Fax:970-346-9800
Practice Address - Street 1:525 W OAK ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2612
Practice Address - Country:US
Practice Address - Phone:970-494-4300
Practice Address - Fax:970-346-9800
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC-6179101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)