Provider Demographics
NPI:1821593534
Name:WADSWORTH, DAWN CARLISLE (MS, BCBA,)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:CARLISLE
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:MS, BCBA,
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:ANNE
Other - Last Name:CARLISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12300 BANNOCK ST UNIT 20102
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-2167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1942 BROADWAY STE 314C
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5233
Practice Address - Country:US
Practice Address - Phone:720-778-0218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1-18-30000103K00000X
AZBEH-000917103K00000X
CA1-18-30000103K00000X
CO1-18-30000103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000159528Medicaid
1-18-30000OtherBCBA CERTIFICATE
AZ149301Medicaid