Basic Information
Provider Information | |||||||||
NPI: | 1376914952 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARRS | ||||||||
FirstName: | KRISTIN | ||||||||
MiddleName: | JARVIS | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 60 LOUIS PRIMA DR | ||||||||
Address2: |   | ||||||||
City: | COVINGTON | ||||||||
State: | LA | ||||||||
PostalCode: | 704335903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9853275427 | ||||||||
FaxNumber: | 9853278800 | ||||||||
Practice Location | |||||||||
Address1: | 250 MAX DR STE 102 | ||||||||
Address2: |   | ||||||||
City: | CASTLE PINES | ||||||||
State: | CO | ||||||||
PostalCode: | 801089518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036493350 | ||||||||
FaxNumber: | 3036493378 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2015 | ||||||||
LastUpdateDate: | 04/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW.09925211 | CO | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 11314 | LA | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.