Provider Demographics
NPI:1801334586
Name:MARCANTONIO, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MARCANTONIO
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 1:600 S CHERRY ST STE 217
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CO
Mailing Address - Zip Code:80246-1704
Mailing Address - Country:US
Mailing Address - Phone:303-861-1916
Mailing Address - Fax:
Practice Address - Street 1:600 S CHERRY ST STE 217
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CO
Practice Address - Zip Code:80246-1704
Practice Address - Country:US
Practice Address - Phone:303-861-1916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12869101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health