Provider Demographics
NPI:1922822246
Name:DAVIDSON-VADER, MARIAH (LPC)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:DAVIDSON-VADER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W DENVER AVE APT A
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-3382
Mailing Address - Country:US
Mailing Address - Phone:303-257-5487
Mailing Address - Fax:
Practice Address - Street 1:1 WESTERN WAY
Practice Address - Street 2:CRYSTAL HALL 104
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230
Practice Address - Country:US
Practice Address - Phone:970-648-7128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000680224Z00000X
COLPC.0021358101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant