Basic Information
| Provider Information | |||||||||
| NPI: | 1548930076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMAGATA | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | GRIEBEL | ||||||||
| OtherFirstName: | JAMIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1870 W 122ND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802342075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038533500 | ||||||||
| FaxNumber: | 3038533702 | ||||||||
| Practice Location | |||||||||
| Address1: | 11285 HIGHLINE DR | ||||||||
| Address2: | |||||||||
| City: | NORTHGLENN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802333076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038533500 | ||||||||
| FaxNumber: | 3038533702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2021 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | LPC.0013704 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.