Provider Demographics
NPI:1881185940
Name:KIECKHABEN, MANDY SUSANNE
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:SUSANNE
Last Name:KIECKHABEN
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 1:411 LAKEWOOD CIR STE C201
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2668
Mailing Address - Country:US
Mailing Address - Phone:719-238-8205
Mailing Address - Fax:
Practice Address - Street 1:411 LAKEWOOD CIR STE C201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2668
Practice Address - Country:US
Practice Address - Phone:719-238-8205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor