Provider Demographics
NPI:1629092291
Name:PFAFFLY, CAROL J (PHD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:PFAFFLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9380
Mailing Address - Country:US
Mailing Address - Phone:719-275-2351
Mailing Address - Fax:719-269-9386
Practice Address - Street 1:3225 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9380
Practice Address - Country:US
Practice Address - Phone:719-275-2351
Practice Address - Fax:719-269-9386
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO176106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07176001Medicaid