Provider Demographics
NPI:1194231068
Name:MANCINI, DUSTIN MAX (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:MAX
Last Name:MANCINI
Suffix:
Gender:M
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W HALLAM ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1158
Mailing Address - Country:US
Mailing Address - Phone:970-309-4732
Mailing Address - Fax:
Practice Address - Street 1:1280 S UTE AVE STE 16
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-2259
Practice Address - Country:US
Practice Address - Phone:970-309-4732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC0014597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional