Organization
SAMPLE SUPPORTS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CARMEN SAMPLE LCSW (EXECUTIVE DIRECTOR)
(720) 684-6102
Entity
Organization
Contact information
Practice address
606 MOUNTAIN VIEW AVE, LONGMONT, CO 80501-2779
(720) 684-6102
(303) 261-8216
Mailing address
606 MOUNTAIN VIEW AVE, LONGMONT, CO 80501-2779
(720) 684-6102
(303) 261-8216
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
—
—
251S00000X
Community/Behavioral Health Agency
Primary
—
—
373H00000X
Day Training/Habilitation Specialist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
40078256
—
CO
Enumeration date
02/15/2011
Last updated
01/31/2023
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