Basic Information
| Provider Information | |||||||||
| NPI: | 1003980061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINZ | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JANSEN | ||||||||
| OtherFirstName: | MARY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5299 S CUBMONT DR | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804397308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035810277 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 115 PARKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726340 | ||||||||
| FaxNumber: | 7194474791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 991014 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.