Provider Demographics
NPI:1942439138
Name:BLICKENDERFER, KATIE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BLICKENDERFER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:SHOARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 RUSKIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910
Mailing Address - Country:US
Mailing Address - Phone:719-572-6100
Mailing Address - Fax:719-572-6080
Practice Address - Street 1:875 W MORENO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-572-6200
Practice Address - Fax:719-572-6299
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0072491041S0200X, 104100000X
CO679104100000X
COCSW099230081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker