Provider Demographics
NPI:1609104991
Name:SAMPLE, CARMEN LOUISE (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LOUISE
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 TERRY ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5930
Mailing Address - Country:US
Mailing Address - Phone:303-523-8057
Mailing Address - Fax:303-772-0629
Practice Address - Street 1:229 TERRY ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5930
Practice Address - Country:US
Practice Address - Phone:303-523-8057
Practice Address - Fax:303-772-0629
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO396104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker