Basic Information
Provider Information | |||||||||
NPI: | 1609052869 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MASHINTER | ||||||||
FirstName: | LACEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 400 | ||||||||
Address2: |   | ||||||||
City: | COTOPAXI | ||||||||
State: | CO | ||||||||
PostalCode: | 81223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7192855121 | ||||||||
FaxNumber: | 7192189994 | ||||||||
Practice Location | |||||||||
Address1: | 8671 SOUTH QUEBEC ST | ||||||||
Address2: | STE 200 | ||||||||
City: | HIGHLANDS RANCH | ||||||||
State: | CO | ||||||||
PostalCode: | 80130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888526672 | ||||||||
FaxNumber: | 3058914228 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2008 | ||||||||
LastUpdateDate: | 10/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 969 | CO | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 99124335 | 05 | CO |   | MEDICAID |