Provider Demographics
NPI:1023455268
Name:URSICH, MARY ANN (MA, LAC, LMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:URSICH
Suffix:
Gender:F
Credentials:MA, LAC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 21ST AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1441
Mailing Address - Country:US
Mailing Address - Phone:303-834-9369
Mailing Address - Fax:303-834-9396
Practice Address - Street 1:420 21ST AVE STE 113
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1441
Practice Address - Country:US
Practice Address - Phone:303-834-9369
Practice Address - Fax:303-834-9396
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000339101YA0400X
COMFT.0001573106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)