Provider Demographics
NPI:1225571763
Name:BELONICK, DANIEL (LCSW, MDIV)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BELONICK
Suffix:
Gender:M
Credentials:LCSW, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 BROADWAY ST STE 210
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3338
Mailing Address - Country:US
Mailing Address - Phone:970-703-5746
Mailing Address - Fax:
Practice Address - Street 1:350 BROADWAY ST STE 210
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-3338
Practice Address - Country:US
Practice Address - Phone:970-703-5746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT58.0096471041C0700X
CO99270311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical