Basic Information
| Provider Information | |||||||||
| NPI: | 1144479197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIVAR | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3595 S TELLER ST | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802352014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034254950 | ||||||||
| FaxNumber: | 3034325939 | ||||||||
| Practice Location | |||||||||
| Address1: | 3595 S TELLER ST | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802352014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034254950 | ||||||||
| FaxNumber: | 3034325939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW.09924412 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.