Provider Demographics
NPI:1093101669
Name:GULLICKSRUD, MARISA A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:A
Last Name:GULLICKSRUD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 ALBION ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-1028
Mailing Address - Country:US
Mailing Address - Phone:303-399-9489
Mailing Address - Fax:
Practice Address - Street 1:1501 ALBION ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-1028
Practice Address - Country:US
Practice Address - Phone:303-399-9489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical