Provider Demographics
NPI:1851874515
Name:ANTLERS CREEK COUNSELING CENTER, PLLC
Entity Type:Organization
Organization Name:ANTLERS CREEK COUNSELING CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTINEZ-EPPERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CACII
Authorized Official - Phone:719-394-8797
Mailing Address - Street 1:12106 RIO SECCO RD
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-4032
Mailing Address - Country:US
Mailing Address - Phone:719-394-8797
Mailing Address - Fax:
Practice Address - Street 1:12106 RIO SECCO RD
Practice Address - Street 2:
Practice Address - City:PEYTON
Practice Address - State:CO
Practice Address - Zip Code:80831-4032
Practice Address - Country:US
Practice Address - Phone:719-220-8662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-10
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099236541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1911930832Medicaid