Healthcare Provider Details

I. General information

NPI: 1245190115
Provider Name (Legal Business Name): KATHERINE MARIE DICKEN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4790 TABLE MESA DR STE 202
BOULDER CO
80305-5660
US

IV. Provider business mailing address

322 LAUREL ST
BROOMFIELD CO
80020-2035
US

V. Phone/Fax

Practice location:
  • Phone: 720-263-0334
  • Fax:
Mailing address:
  • Phone: 480-436-1912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW.0009925915
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: