Provider Demographics
NPI:1679147193
Name:DEVELOPMENTAL DISABILITIES CENTER
Entity Type:Organization
Organization Name:DEVELOPMENTAL DISABILITIES CENTER
Other - Org Name:IMAGINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-641-6342
Mailing Address - Street 1:1400 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2790
Mailing Address - Country:US
Mailing Address - Phone:303-665-7789
Mailing Address - Fax:
Practice Address - Street 1:1665 COAL CREEK DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2784
Practice Address - Country:US
Practice Address - Phone:303-665-7789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42800145Medicaid