Provider Demographics
NPI:1891394177
Name:EXPERIENTIAL FAMILY THERAPY AND TRAINING CENTER, LLC
Entity Type:Organization
Organization Name:EXPERIENTIAL FAMILY THERAPY AND TRAINING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLION
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT, LAC, RPT
Authorized Official - Phone:720-757-1988
Mailing Address - Street 1:2974 W CHENANGO AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80110-6308
Mailing Address - Country:US
Mailing Address - Phone:720-757-1988
Mailing Address - Fax:
Practice Address - Street 1:7175 W JEFFERSON AVE STE 1200
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2380
Practice Address - Country:US
Practice Address - Phone:720-757-1988
Practice Address - Fax:720-306-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COACA.0001175OtherLICENSED ADDICTION COUNSELOR
1356798078OtherINDIVIDUAL NPI
COMFT.0001840OtherMARRIAGE AND FAMILY THERAPIST