Healthcare Provider Details

I. General information

NPI: 1609753052
Provider Name (Legal Business Name): MAYA STACKHOUSE MSW, LSW
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 E MLK JR BLVD
DENVER CO
80205-4976
US

IV. Provider business mailing address

3711 N VINE ST
DENVER CO
80205-3529
US

V. Phone/Fax

Practice location:
  • Phone: 303-333-8360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW.0009927651
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: