Provider Demographics
NPI:1194403238
Name:FORMATION COUNSELING CENTER
Entity type:Organization
Organization Name:FORMATION COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOERTJE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, NCC, LPC
Authorized Official - Phone:312-369-9422
Mailing Address - Street 1:128 S TEJON ST STE 405
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2212
Mailing Address - Country:US
Mailing Address - Phone:312-369-9422
Mailing Address - Fax:719-755-4662
Practice Address - Street 1:128 S TEJON ST STE 405
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2212
Practice Address - Country:US
Practice Address - Phone:312-369-9422
Practice Address - Fax:719-755-4662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-10
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty