Provider Demographics
NPI:1740777507
Name:STACY REUILLE-DUPONT, LLC
Entity Type:Organization
Organization Name:STACY REUILLE-DUPONT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:REUILLE-DUPONT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:970-749-8227
Mailing Address - Street 1:1305 ESCALANTE DR # 203
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-8931
Mailing Address - Country:US
Mailing Address - Phone:970-749-8227
Mailing Address - Fax:
Practice Address - Street 1:1305 ESCALANTE DR # 203
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-8931
Practice Address - Country:US
Practice Address - Phone:970-749-8227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4577261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49670379Medicaid