Provider Demographics
NPI:1700644846
Name:GLICK, KELLY R (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:GLICK
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 1:3207 KITTERY CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2359
Mailing Address - Country:US
Mailing Address - Phone:970-420-9595
Mailing Address - Fax:
Practice Address - Street 1:3207 KITTERY CT
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2359
Practice Address - Country:US
Practice Address - Phone:970-420-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO01741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical