Provider Demographics
NPI:1770040107
Name:RISEDORF, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:RISEDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 S NELSON CT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80235-1150
Mailing Address - Country:US
Mailing Address - Phone:720-261-4153
Mailing Address - Fax:
Practice Address - Street 1:7200 E DRY CREEK RD
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-2537
Practice Address - Country:US
Practice Address - Phone:866-300-0822
Practice Address - Fax:303-600-9933
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-18-72182106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO106S00000XOtherBACB