Healthcare Provider Details

I. General information

NPI: 1346454188
Provider Name (Legal Business Name): CHAPPELL FAIN MARMON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 ALPINE AVE. STE. E
BOULDER CO
80304
US

IV. Provider business mailing address

4019 WONDERLAND HILL AVE.
BOULDER CO
80304
US

V. Phone/Fax

Practice location:
  • Phone: 303-437-4158
  • Fax:
Mailing address:
  • Phone: 303-437-4158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1303
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: