Provider Demographics
NPI:1477974368
Name:WIGHTMAN, DALE RUSSELL
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:RUSSELL
Last Name:WIGHTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W DAVIES AVE N
Mailing Address - Street 2:STE 105
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5211
Mailing Address - Country:US
Mailing Address - Phone:303-730-1717
Mailing Address - Fax:303-730-1531
Practice Address - Street 1:141 W DAVIES AVE N
Practice Address - Street 2:STE 105
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-5211
Practice Address - Country:US
Practice Address - Phone:303-730-1717
Practice Address - Fax:303-730-1531
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005573101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional