Provider Demographics
NPI:1104248947
Name:STOUT STREET FOUNDATION
Entity type:Organization
Organization Name:STOUT STREET FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF PROGRAMS
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:PETRUCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:CAC III
Authorized Official - Phone:303-321-2533
Mailing Address - Street 1:7251 E 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-4714
Mailing Address - Country:US
Mailing Address - Phone:303-321-2533
Mailing Address - Fax:303-468-6199
Practice Address - Street 1:7201 E 49TH AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-4714
Practice Address - Country:US
Practice Address - Phone:303-321-2533
Practice Address - Fax:303-468-6184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO139909324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17085071Medicaid