Basic Information
| Provider Information | |||||||||
| NPI: | 1467577932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUARLES | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 WESTERN AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803012709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034154770 | ||||||||
| FaxNumber: | 3034154769 | ||||||||
| Practice Location | |||||||||
| Address1: | 1755 48TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803012711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034945263 | ||||||||
| FaxNumber: | 3034945265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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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 | CSW.00000672 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 11221569 | 05 | CO | MEDICAID |