Provider Demographics
NPI:1790234342
Name:CROSS, KELLY SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:CROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4176 CULEBRA CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1630
Mailing Address - Country:US
Mailing Address - Phone:720-936-8202
Mailing Address - Fax:
Practice Address - Street 1:2625 PINE ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-3804
Practice Address - Country:US
Practice Address - Phone:720-936-8202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099240211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical