=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518738012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STASIS BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2024
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1495 CANYON BLVD
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80302-5367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-571-5613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4845 PEARL EAST CIR STE 118 PMB 38489
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. CHRISTOPHER J SMALLWOOD
-----------------------------------------------------
Credential | PHD, PMHNP-BC
-----------------------------------------------------
Telephone | 512-995-8905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------