Provider Demographics
NPI:1821116062
Name:WEBER, KATHY LYNN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:LYNN
Last Name:WEBER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-0074
Mailing Address - Country:US
Mailing Address - Phone:417-839-8100
Mailing Address - Fax:719-465-3135
Practice Address - Street 1:1219 LAKE PLAZA DR STE B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3509
Practice Address - Country:US
Practice Address - Phone:417-881-2339
Practice Address - Fax:417-886-3291
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW000017011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493264402Medicaid