Provider Demographics
NPI:1538477351
Name:SALLEY, MARIAN (LCSW LAC CGP ACS)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:SALLEY
Suffix:
Gender:F
Credentials:LCSW LAC CGP ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 HOLIDAY DR UNIT 103
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-2361
Mailing Address - Country:US
Mailing Address - Phone:303-859-2611
Mailing Address - Fax:
Practice Address - Street 1:2299 PEARL ST STE 400F
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-4673
Practice Address - Country:US
Practice Address - Phone:303-859-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001041101YA0400X
CO099237571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)