Healthcare Provider Details

I. General information

NPI: 1275252140
Provider Name (Legal Business Name): YURI SHANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 47TH ST STE F1
BOULDER CO
80301-5550
US

IV. Provider business mailing address

3005 47TH ST STE F1
BOULDER CO
80301-5550
US

V. Phone/Fax

Practice location:
  • Phone: 303-955-6809
  • Fax:
Mailing address:
  • Phone: 303-955-6809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09932355
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: