Provider Demographics
NPI:1487106365
Name:GONZALES, STACIE MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:MARIE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 CHAMPA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2529
Mailing Address - Country:US
Mailing Address - Phone:719-543-8711
Mailing Address - Fax:303-312-2217
Practice Address - Street 1:2130 STOUT ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2827
Practice Address - Country:US
Practice Address - Phone:303-293-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0106614101Y00000X
1041C0700X
COCSW.099278741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor