Provider Demographics
NPI:1033225974
Name:KWIECIEN, SUSAN M
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:KWIECIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E PIKES PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1193
Mailing Address - Country:US
Mailing Address - Phone:303-486-5504
Mailing Address - Fax:303-486-5501
Practice Address - Street 1:825 E PIKES PEAK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3635
Practice Address - Country:US
Practice Address - Phone:719-776-8325
Practice Address - Fax:719-776-8568
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFT294106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4366Medicare ID - Type Unspecified