Provider Demographics
NPI:1902350788
Name:COLLABORATIVE SERVICE FOR CHANGE PC
Entity Type:Organization
Organization Name:COLLABORATIVE SERVICE FOR CHANGE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KISICKI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:303-433-0188
Mailing Address - Street 1:2480 W 26TH AVE
Mailing Address - Street 2:SUITE 130B
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-5309
Mailing Address - Country:US
Mailing Address - Phone:303-433-0188
Mailing Address - Fax:303-433-6145
Practice Address - Street 1:2480 W 26TH AVE
Practice Address - Street 2:SUITE 130B
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-5309
Practice Address - Country:US
Practice Address - Phone:303-433-0188
Practice Address - Fax:303-433-6145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO992298251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42427851Medicaid