Provider Demographics
NPI:1659125292
Name:STAHL-WHITAKER, MACKENZIE S
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:S
Last Name:STAHL-WHITAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6684 LUCKY STAR LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-7470
Mailing Address - Country:US
Mailing Address - Phone:765-421-9273
Mailing Address - Fax:
Practice Address - Street 1:1942 BROADWAY STE 314C
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5233
Practice Address - Country:US
Practice Address - Phone:719-301-5726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.0009925357104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker