Provider Demographics
NPI:1730217787
Name:NORTH COLORADO BEHAVIORAL HEALTH OF FORT COLLINS, LLC
Entity type:Organization
Organization Name:NORTH COLORADO BEHAVIORAL HEALTH OF FORT COLLINS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:P
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-224-0495
Mailing Address - Street 1:3825 E MULBERRY ST
Mailing Address - Street 2:UNIT 5C
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-8574
Mailing Address - Country:US
Mailing Address - Phone:970-224-0495
Mailing Address - Fax:970-224-0497
Practice Address - Street 1:3825 E MULBERRY ST
Practice Address - Street 2:UNIT 5C
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-8574
Practice Address - Country:US
Practice Address - Phone:970-224-0495
Practice Address - Fax:970-224-0497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1579-01101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98323032Medicaid