Provider Demographics
NPI:1710631379
Name:SOUTHWEST COLORADO DBT LLC
Entity Type:Organization
Organization Name:SOUTHWEST COLORADO DBT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LAC
Authorized Official - Phone:414-315-0897
Mailing Address - Street 1:1309 E 3RD AVE UNIT B-5
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5255
Mailing Address - Country:US
Mailing Address - Phone:414-315-0897
Mailing Address - Fax:
Practice Address - Street 1:1309 E 3RD AVE UNIT B-5
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5255
Practice Address - Country:US
Practice Address - Phone:414-315-0897
Practice Address - Fax:970-459-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1225620172Medicaid
CO1114449063Medicaid
WI1336586981Medicaid