Provider Demographics
NPI:1497262612
Name:DEBLOCK, KATHRYN L (MA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:DEBLOCK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 N ACADEMY BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5369
Mailing Address - Country:US
Mailing Address - Phone:719-466-4809
Mailing Address - Fax:719-368-8399
Practice Address - Street 1:2989 BROADMOOR VALLEY RD STE D
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4403
Practice Address - Country:US
Practice Address - Phone:719-576-1316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11940106E00000X
CORBT-17-39605106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician