Provider Demographics
NPI:1093763146
Name:WIGHT, KEVIN S (MSW, LCSW, CACIII)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:WIGHT
Suffix:
Gender:M
Credentials:MSW, LCSW, CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 28 3/4 RD
Mailing Address - Street 2:BLDG A
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-5016
Mailing Address - Country:US
Mailing Address - Phone:970-683-7107
Mailing Address - Fax:970-683-7167
Practice Address - Street 1:515 28 3/4 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-5016
Practice Address - Country:US
Practice Address - Phone:970-241-6023
Practice Address - Fax:970-242-8330
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2921041C0700X
CO7224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)