Provider Demographics
NPI:1366066110
Name:LAFATA, IONE RENEE
Entity type:Individual
Prefix:DR
First Name:IONE
Middle Name:RENEE
Last Name:LAFATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 SPRUCE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-9757
Mailing Address - Country:US
Mailing Address - Phone:719-900-8894
Mailing Address - Fax:
Practice Address - Street 1:31 SPRUCE LAKE DR
Practice Address - Street 2:
Practice Address - City:DIVIDE
Practice Address - State:CO
Practice Address - Zip Code:80814-9757
Practice Address - Country:US
Practice Address - Phone:719-900-8894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0111058103TP2701X, 103TB0200X, 103TS0200X, 103TC1900X
GUIMFT0003106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty