Provider Demographics
NPI:1881147387
Name:DITZLER, KIMBERLY ANNE (MS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:DITZLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2404
Mailing Address - Country:US
Mailing Address - Phone:970-549-1182
Mailing Address - Fax:970-549-1400
Practice Address - Street 1:300 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501
Practice Address - Country:US
Practice Address - Phone:970-549-1182
Practice Address - Fax:970-549-1400
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPP.0001432101Y00000X
COLPCC.0014784101Y00000X
COLPC.0014854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0014854OtherSTATE LICENSURE