Provider Demographics
NPI:1275060386
Name:ROM 12-2 COUNSELING
Entity Type:Organization
Organization Name:ROM 12-2 COUNSELING
Other - Org Name:MIND RENEWAL BEHAVIORAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLAFAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:719-465-2582
Mailing Address - Street 1:660 SOUTHPOINTE CT STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3874
Mailing Address - Country:US
Mailing Address - Phone:719-465-2582
Mailing Address - Fax:719-465-2643
Practice Address - Street 1:660 SOUTHPOINTE CT STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3874
Practice Address - Country:US
Practice Address - Phone:719-465-2582
Practice Address - Fax:719-465-2643
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROM 12-2 COUNSELING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-19
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5586101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1174713325OtherINDIVIDUAL NPI
CO671490Medicaid