Provider Demographics
NPI:1295951366
Name:STALL, MARY (PSYD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:STALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6081 S QUEBEC ST
Mailing Address - Street 2:SUITE202
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80111-4536
Mailing Address - Country:US
Mailing Address - Phone:303-322-1776
Mailing Address - Fax:303-221-0388
Practice Address - Street 1:6081 S QUEBEC ST
Practice Address - Street 2:SUITE202
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80111-4536
Practice Address - Country:US
Practice Address - Phone:303-322-1776
Practice Address - Fax:303-221-0388
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2799103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical