Provider Demographics
NPI:1801407382
Name:FAWCETT, MARY EMMA (MFTC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:EMMA
Last Name:FAWCETT
Suffix:
Gender:
Credentials:MFTC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:SCHIMKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2950 TENNYSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-3029
Mailing Address - Country:US
Mailing Address - Phone:303-433-2541
Mailing Address - Fax:
Practice Address - Street 1:12303 AIRPORT WAY STE 125
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-2729
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0017575101Y00000X
COMFTC.0014311106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COLPCC.0017575Medicaid