Provider Demographics
NPI:1184039919
Name:PENNEY-SYSUM, KIMBERLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PENNEY-SYSUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:PENNEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2032 LOWE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5741
Mailing Address - Country:US
Mailing Address - Phone:970-232-1156
Mailing Address - Fax:
Practice Address - Street 1:2032 LOWE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5741
Practice Address - Country:US
Practice Address - Phone:970-232-1156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9926401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical