Healthcare Provider Details

I. General information

NPI: 1568168375
Provider Name (Legal Business Name): LACY SCHROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LACY SIMON

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 02/02/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4280 GREENBRIAR BLVD
BOULDER CO
80305-7073
US

IV. Provider business mailing address

PO BOX 3326
BOULDER CO
80307-3326
US

V. Phone/Fax

Practice location:
  • Phone: 303-808-9122
  • Fax:
Mailing address:
  • Phone: 970-363-4835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09928609
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: