Provider Demographics
NPI:1609305861
Name:REISEL, MARY KATHRYN (LCSW, ATR)
Entity Type:Individual
Prefix:MRS
First Name:MARY KATHRYN
Middle Name:
Last Name:REISEL
Suffix:
Gender:F
Credentials:LCSW, ATR
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:REISEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:910 HOMER CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2760
Mailing Address - Country:US
Mailing Address - Phone:773-829-3329
Mailing Address - Fax:
Practice Address - Street 1:400 E SIMPSON ST STE G1
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2350
Practice Address - Country:US
Practice Address - Phone:720-336-8859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000010321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical