Provider Demographics
NPI:1063192276
Name:THE OTHER THERAPY ONLINE, LLC
Entity type:Organization
Organization Name:THE OTHER THERAPY ONLINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-319-7190
Mailing Address - Street 1:53 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-9102
Mailing Address - Country:US
Mailing Address - Phone:970-319-7190
Mailing Address - Fax:
Practice Address - Street 1:1650 38TH ST STE 100E
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2624
Practice Address - Country:US
Practice Address - Phone:970-319-7190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty