Provider Demographics
NPI:1982853073
Name:ROCKY MOUNTAIN MEMORY CENTER PLLC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN MEMORY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAUREN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:970-221-1073
Mailing Address - Street 1:2801 REMINGTON ST STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2566
Mailing Address - Country:US
Mailing Address - Phone:970-221-1073
Mailing Address - Fax:
Practice Address - Street 1:951 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2522
Practice Address - Country:US
Practice Address - Phone:970-221-1073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1990103G00000X
CO1024531225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69323780Medicaid
CO1427101708Medicare NSC