Healthcare Provider Details

I. General information

NPI: 1578977153
Provider Name (Legal Business Name): MARIANN STANLEY LPC, CAC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3470 BROADWAY ST
BOULDER CO
80304-1824
US

IV. Provider business mailing address

3470 BROADWAY ST
BOULDER CO
80304-1824
US

V. Phone/Fax

Practice location:
  • Phone: 303-441-1463
  • Fax:
Mailing address:
  • Phone: 303-441-1463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3211
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3942
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: