Provider Demographics
NPI:1275793770
Name:GAYLORD, WENDY ELLIS (LCSW)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:ELLIS
Last Name:GAYLORD
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 1:5052 N FOOTHILLS HWY
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9363
Mailing Address - Country:US
Mailing Address - Phone:720-357-4448
Mailing Address - Fax:
Practice Address - Street 1:2346 BROADWAY ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4107
Practice Address - Country:US
Practice Address - Phone:720-357-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR051672-11041C0700X
CO9431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02399273Medicaid
Q21424Medicare UPIN
IA0565Medicare PIN