Provider Demographics
NPI:1760538128
Name:DEPOILLY, STACEY RENEE (MA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RENEE
Last Name:DEPOILLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3980 BUNK HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-2231
Mailing Address - Country:US
Mailing Address - Phone:719-638-4588
Mailing Address - Fax:719-520-9570
Practice Address - Street 1:2812 E BIJOU ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-6371
Practice Address - Country:US
Practice Address - Phone:719-520-5656
Practice Address - Fax:719-520-9570
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONOT LICENSED101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57153060Medicaid