Provider Demographics
NPI:1104255538
Name:ALLPORT, TIMOTHY (CAC III)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:ALLPORT
Suffix:
Gender:M
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EAST SOUTH BOULDER ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026
Mailing Address - Country:US
Mailing Address - Phone:303-665-7037
Mailing Address - Fax:720-890-7111
Practice Address - Street 1:100 EAST SOUTH BOULDER ROAD
Practice Address - Street 2:SUITE 105
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026
Practice Address - Country:US
Practice Address - Phone:303-665-7037
Practice Address - Fax:720-890-7111
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101YA0400X
CO3791101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80776230Medicaid