Provider Demographics
NPI:1679628952
Name:HART, JAMES ROBERT (BA CAC I)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:HART
Suffix:
Gender:M
Credentials:BA CAC I
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:ROBERT
Other - Last Name:INGERSOLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QMHA, BA
Mailing Address - Street 1:PO BOX 499
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:CO
Mailing Address - Zip Code:80540-0499
Mailing Address - Country:US
Mailing Address - Phone:720-310-8010
Mailing Address - Fax:303-823-9355
Practice Address - Street 1:304 MAIN STREET, UNIT C
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:CO
Practice Address - Zip Code:80540
Practice Address - Country:US
Practice Address - Phone:720-310-8010
Practice Address - Fax:303-823-9355
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6850101YA0400X
CO13918101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator