Provider Demographics
NPI:1871943548
Name:LAWRENCE, THERESA (BS, CAC III)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:BS, CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 KELLY JOHNSON BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5250 PIKES PEAK HWY
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:CO
Practice Address - Zip Code:80809-1110
Practice Address - Country:US
Practice Address - Phone:719-684-7846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO06355101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)