Provider Demographics
NPI:1952847618
Name:TEDFORD, KINSEY NICOLE
Entity Type:Individual
Prefix:
First Name:KINSEY
Middle Name:NICOLE
Last Name:TEDFORD
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 1:155 S 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-4559
Mailing Address - Country:US
Mailing Address - Phone:720-626-3396
Mailing Address - Fax:
Practice Address - Street 1:2111 CHAMPA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2529
Practice Address - Country:US
Practice Address - Phone:303-312-2217
Practice Address - Fax:303-293-2309
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPC.0013819101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000159057Medicaid