Provider Demographics
NPI:1396877692
Name:KAISNER, MANDY J (LPC)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:J
Last Name:KAISNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:J
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSY PH D
Mailing Address - Street 1:3225 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9380
Mailing Address - Country:US
Mailing Address - Phone:719-275-2351
Mailing Address - Fax:719-269-9386
Practice Address - Street 1:714 FRONT ST
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3921
Practice Address - Country:US
Practice Address - Phone:719-486-0985
Practice Address - Fax:719-486-0986
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5826101YP2500X
103T00000X
5826101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
93336535Medicare UPIN