Provider Demographics
NPI:1558852566
Name:SARAH BRESEKE
Entity type:Organization
Organization Name:SARAH BRESEKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRESEKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-639-0112
Mailing Address - Street 1:616 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-1938
Mailing Address - Country:US
Mailing Address - Phone:573-639-0112
Mailing Address - Fax:
Practice Address - Street 1:1136 E STUART ST STE 101
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1195
Practice Address - Country:US
Practice Address - Phone:573-639-0112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0004992101Y00000X
CO0004992261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty