MEDICARE: MARC AZOULAY MA, LPCC, LAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	ACD.0000611	CO
2	101YP2500X	Professional Counselor	LPCC.0014605	CO

General Provider Information

NPI Number	:	1851740625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARC AZOULAY MA, LPCC, LAC

Provider Business Mailing Address
First Line	:	3050 BROADWAY ST
Second Line	:	SUITE 300
City	:	BOULDER
State	:	CO
Zip	:	80304-3154
Country	:	US
Telephone Number	:	301-442-9119
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 BROADWAY ST
Second Line	:	SUITE 300
City	:	BOULDER
State	:	CO
Zip	:	80304-3154
Country	:	US
Telephone Number	:	301-442-9119
Fax Number	:

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

Provider Enumeration Date	:	06/12/2016
Last Update Date	:	06/12/2016

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