Provider Demographics
NPI:1508581612
Name:CHACON, CHASTIDY MARIAH (LPC)
Entity Type:Individual
Prefix:
First Name:CHASTIDY
Middle Name:MARIAH
Last Name:CHACON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140-0514
Mailing Address - Country:US
Mailing Address - Phone:469-810-2021
Mailing Address - Fax:
Practice Address - Street 1:322 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:LA JARA
Practice Address - State:CO
Practice Address - Zip Code:81140
Practice Address - Country:US
Practice Address - Phone:719-587-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18539101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional