Provider Demographics
NPI:1962541763
Name:KORMYLO, MARA BRAUN (LCSW)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:BRAUN
Last Name:KORMYLO
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:PO BOX 3291
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80437-3291
Mailing Address - Country:US
Mailing Address - Phone:303-324-5469
Mailing Address - Fax:
Practice Address - Street 1:112 N RUBEY DR UNIT 130
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-3211
Practice Address - Country:US
Practice Address - Phone:303-324-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9925261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical