Provider Demographics
NPI:1689175960
Name:DENISE E GENDREAU LCSW
Entity Type:Organization
Organization Name:DENISE E GENDREAU LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-231-1294
Mailing Address - Street 1:5455 COUNTY ROAD 23
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:CO
Mailing Address - Zip Code:81432-9545
Mailing Address - Country:US
Mailing Address - Phone:970-316-1994
Mailing Address - Fax:
Practice Address - Street 1:100 WEST COLORADO AVENUE
Practice Address - Street 2:SUITE 227
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435-8143
Practice Address - Country:US
Practice Address - Phone:970-316-1994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.000021021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty