Provider Demographics
NPI:1124725130
Name:TURQUOISE TRAIL THERAPY LLC
Entity type:Organization
Organization Name:TURQUOISE TRAIL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANNA
Authorized Official - Last Name:SHORTER-KING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:719-276-2550
Mailing Address - Street 1:1191 CANON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9163
Mailing Address - Country:US
Mailing Address - Phone:719-276-2550
Mailing Address - Fax:
Practice Address - Street 1:1191 CANON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9163
Practice Address - Country:US
Practice Address - Phone:719-276-2550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty