Provider Demographics
NPI:1659815769
Name:VIOLET MOUNTAIN LIFE CENTER, INC.
Entity Type:Organization
Organization Name:VIOLET MOUNTAIN LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RYDER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:719-201-5735
Mailing Address - Street 1:1353 S 8TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-7320
Mailing Address - Country:US
Mailing Address - Phone:719-201-5735
Mailing Address - Fax:
Practice Address - Street 1:1353 S 8TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-7320
Practice Address - Country:US
Practice Address - Phone:719-201-5735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000390106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty