Provider Demographics
NPI:1568668341
Name:WESTERN SLOPE INNERCHANGE
Entity Type:Organization
Organization Name:WESTERN SLOPE INNERCHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:970-874-0875
Mailing Address - Street 1:115 GRAND AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-2017
Mailing Address - Country:US
Mailing Address - Phone:970-874-0875
Mailing Address - Fax:970-874-5443
Practice Address - Street 1:115 GRAND AVE STE 1
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2017
Practice Address - Country:US
Practice Address - Phone:970-874-0875
Practice Address - Fax:970-874-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3712101YA0400X
CO1490103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO035354OtherVALUE OPTIONS MEDICAID NUMBER
CO07014905Medicaid
CO07014905Medicaid
COC808902Medicare PIN