MEDICARE: MRS. TIA L STALLARD LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	12049	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932635950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIA L STALLARD LCSW

Provider Business Mailing Address
First Line	:	1650 COCHRANE CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80913-4613
Country	:	US
Telephone Number	:	719-526-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1364 BARKELEY AVE BLDG 1150
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80913-4161
Country	:	US
Telephone Number	:	719-526-0175
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	04/17/2024

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