Provider Demographics
NPI:1073988267
Name:WILLECKE, KAITLYN ALEXANDRA
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ALEXANDRA
Last Name:WILLECKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:ALEXANDRA
Other - Last Name:KURZDORFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4851 INDEPENDENCE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6715
Mailing Address - Country:US
Mailing Address - Phone:303-425-0300
Mailing Address - Fax:303-432-5071
Practice Address - Street 1:4851 INDEPENDENCE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6715
Practice Address - Country:US
Practice Address - Phone:303-425-0300
Practice Address - Fax:303-432-5071
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104100000X
CO99223011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker