Provider Demographics
NPI:1104183136
Name:WANTZ, KIMBERLY ANN (MSW,LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:WANTZ
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5197 GALLATIN PLACE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303
Mailing Address - Country:US
Mailing Address - Phone:303-975-6061
Mailing Address - Fax:
Practice Address - Street 1:1950 MOUNTAIN VIEW AVENUE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-651-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical