Provider Demographics
NPI:1821698812
Name:ROCKY MOUNTAIN BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSEN-KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-275-7650
Mailing Address - Street 1:3239 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9380
Mailing Address - Country:US
Mailing Address - Phone:719-275-7650
Mailing Address - Fax:719-275-4209
Practice Address - Street 1:685 CITADEL DR E STE 125
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5316
Practice Address - Country:US
Practice Address - Phone:719-275-7650
Practice Address - Fax:719-275-4209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1063-03Medicaid