Provider Demographics
NPI:1881276996
Name:QUATTLEBAUM, RAEGAN LASHAWN
Entity type:Individual
Prefix:
First Name:RAEGAN
Middle Name:LASHAWN
Last Name:QUATTLEBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 E 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80249-8794
Mailing Address - Country:US
Mailing Address - Phone:303-856-6125
Mailing Address - Fax:
Practice Address - Street 1:16199 GREEN VALLEY RANCH BLVD APT 3024
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239-5727
Practice Address - Country:US
Practice Address - Phone:303-856-6125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0020852101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty