Provider Demographics
NPI:1407987662
Name:COBLENTZ SWAN, KRISTIN ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:ANNE
Last Name:COBLENTZ SWAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:128 SE SOMERSET CT
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-3626
Mailing Address - Country:US
Mailing Address - Phone:816-804-8847
Mailing Address - Fax:816-581-3738
Practice Address - Street 1:7001 BLUE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-5629
Practice Address - Country:US
Practice Address - Phone:816-966-0900
Practice Address - Fax:816-347-3029
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4902104100000X
MO20040328341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498735109Medicaid