Provider Demographics
NPI:1407723497
Name:EMERGENCE PSYCHEDELIC THERAPY, LLC
Entity type:Organization
Organization Name:EMERGENCE PSYCHEDELIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-442-3565
Mailing Address - Street 1:825 S BROADWAY ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5932
Mailing Address - Country:US
Mailing Address - Phone:303-578-8845
Mailing Address - Fax:
Practice Address - Street 1:825 S BROADWAY ST STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5932
Practice Address - Country:US
Practice Address - Phone:303-578-8845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)