MEDICARE: DR. MARILYN COONELLY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1382	CO

General Provider Information

NPI Number	:	1770734089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARILYN COONELLY PH.D.

Provider Business Mailing Address
First Line	:	100 ARAPAHOE AVE STE 7
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80302-5862
Country	:	US
Telephone Number	:	303-938-1870
Fax Number	:	303-413-1203

Provider Business Practice Location Address
First Line	:	100 ARAPAHOE AVE STE 7
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80302-5862
Country	:	US
Telephone Number	:	303-938-1870
Fax Number	:	303-413-1203

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2008
Last Update Date	:	10/06/2008

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