Basic Information
| Provider Information | |||||||||
| NPI: | 1942439138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLICKENDERFER | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SHOARS | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DRIVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726100 | ||||||||
| FaxNumber: | 7195726080 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 W MORENO AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726200 | ||||||||
| FaxNumber: | 7195726299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2009 | ||||||||
| LastUpdateDate: | 09/14/2012 | ||||||||
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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 | 1041S0200X | 007249 | IA | N | Behavioral Health & Social Service Providers | Social Worker | School | 104100000X | 679 | CO | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 007249 | IA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | CSW09923008 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.