Provider Demographics
NPI:1942778469
Name:CONLEY, CARROLL GABRIEL
Entity Type:Individual
Prefix:
First Name:CARROLL
Middle Name:GABRIEL
Last Name:CONLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 S HALIFAX ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-6261
Mailing Address - Country:US
Mailing Address - Phone:303-808-7358
Mailing Address - Fax:
Practice Address - Street 1:11059 E BETHANY DR # 80014
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-2622
Practice Address - Country:US
Practice Address - Phone:303-808-7358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO052081352101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO806295236Medicaid