Provider Demographics
NPI:1336703313
Name:SMITH, MARISTELA (LCSW,PHD)
Entity Type:Individual
Prefix:
First Name:MARISTELA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 N YORK ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-3540
Mailing Address - Country:US
Mailing Address - Phone:720-833-5015
Mailing Address - Fax:866-335-7875
Practice Address - Street 1:3800 N YORK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-3540
Practice Address - Country:US
Practice Address - Phone:720-833-5015
Practice Address - Fax:866-335-7875
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO09925920101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09925920OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES DIVISION OF PROFESSIONS AND OCCUPATIO