Provider Demographics
NPI:1487042974
Name:WICKMAN, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4851 INDEPENDENCE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6715
Mailing Address - Country:US
Mailing Address - Phone:303-425-0030
Mailing Address - Fax:
Practice Address - Street 1:3595 S TELLER ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2014
Practice Address - Country:US
Practice Address - Phone:303-425-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
COLPC.0014096101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health