Provider Demographics
NPI:1609224690
Name:COUNSELING SERVICES OF LONGMONT
Entity Type:Organization
Organization Name:COUNSELING SERVICES OF LONGMONT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DE HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-772-3853
Mailing Address - Street 1:1129 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3703
Mailing Address - Country:US
Mailing Address - Phone:303-772-3853
Mailing Address - Fax:303-772-1718
Practice Address - Street 1:1129 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3703
Practice Address - Country:US
Practice Address - Phone:303-772-3853
Practice Address - Fax:303-772-1718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO178800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1598112112Medicaid
CO1710104112Medicaid