Provider Demographics
NPI:1518738012
Name:RECONSTRUCT PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:RECONSTRUCT PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMALLWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PMHNP-BC
Authorized Official - Phone:512-995-8905
Mailing Address - Street 1:4845 PEARL EAST CIR STE 118 PMB 38489
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1495 CANYON BLVD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5367
Practice Address - Country:US
Practice Address - Phone:800-571-5613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-12
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty