Provider Demographics
NPI:1750879284
Name:VISNICH, JULIE ANDREA
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:ANDREA
Last Name:VISNICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4234
Mailing Address - Country:US
Mailing Address - Phone:970-769-8397
Mailing Address - Fax:
Practice Address - Street 1:1053 MAIN AVE STE 109A
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5568
Practice Address - Country:US
Practice Address - Phone:970-769-8397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
260204467OtherTIN