Provider Demographics
NPI:1508100488
Name:SOUTH DENVER PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:SOUTH DENVER PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:303-730-1144
Mailing Address - Street 1:4 MEADOWBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-4151
Mailing Address - Country:US
Mailing Address - Phone:303-795-9560
Mailing Address - Fax:
Practice Address - Street 1:2305 E ARAPAHOE RD
Practice Address - Street 2:SUITE 242
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122-1522
Practice Address - Country:US
Practice Address - Phone:303-730-1144
Practice Address - Fax:303-795-9561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5737251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1861624033OtherNATIONAL PROVIDER ID