Provider Demographics
NPI:1053837195
Name:DASE, MARY JO (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:DASE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 N WEBER ST OFC 1
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6946
Mailing Address - Country:US
Mailing Address - Phone:719-578-2033
Mailing Address - Fax:719-578-1772
Practice Address - Street 1:2211 N WEBER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6946
Practice Address - Country:US
Practice Address - Phone:719-578-2033
Practice Address - Fax:719-578-1772
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO155101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional