Provider Demographics
NPI:1184723660
Name:DEVEREUX CLEO WALLACE
Entity type:Organization
Organization Name:DEVEREUX CLEO WALLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY IMPROVEMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-438-2265
Mailing Address - Street 1:8405 CHURCH RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-3918
Mailing Address - Country:US
Mailing Address - Phone:303-466-7391
Mailing Address - Fax:
Practice Address - Street 1:8405 CHURCH RANCH BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-3918
Practice Address - Country:US
Practice Address - Phone:303-466-7391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39794323P00000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05350053Medicaid
CO17284554Medicaid