Healthcare Provider Details

I. General information

NPI: 1427767441
Provider Name (Legal Business Name): EMILY BLAIR SLOUGH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY TUCHEK LCSW

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 HOMESTEAD RD
DIVIDE CO
80814-8906
US

IV. Provider business mailing address

280 HOMESTEAD RD
DIVIDE CO
80814-8906
US

V. Phone/Fax

Practice location:
  • Phone: 719-357-8208
  • Fax:
Mailing address:
  • Phone: 719-357-8208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number67581
License Number StateTX

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: