Provider Demographics
NPI:1790032589
Name:VANDENBERG, KATHLEEN J
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:V
Other - Last Name:ECKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:305 CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4248
Mailing Address - Country:US
Mailing Address - Phone:970-663-3500
Mailing Address - Fax:970-292-0898
Practice Address - Street 1:305 CARPENTER RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4248
Practice Address - Country:US
Practice Address - Phone:970-663-3500
Practice Address - Fax:970-292-0898
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CONONEOtherNONE
CONONEOtherNONE