Healthcare Provider Details

I. General information

NPI: 1851439129
Provider Name (Legal Business Name): LORI G. MOSES-BENNETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1634 WALNUT ST SUITE 201
BOULDER CO
80302-5400
US

IV. Provider business mailing address

PO BOX 4174
BOULDER CO
80306-4174
US

V. Phone/Fax

Practice location:
  • Phone: 303-709-7601
  • Fax: 303-665-5501
Mailing address:
  • Phone: 303-709-7601
  • Fax: 303-665-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number992969
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: