Healthcare Provider Details

I. General information

NPI: 1821603085
Provider Name (Legal Business Name): TIMOTHY KLEINKNECHT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 MANHATTAN DR STE 208D
BOULDER CO
80303-4254
US

IV. Provider business mailing address

2727 PINE ST STE 3A
BOULDER CO
80302-3846
US

V. Phone/Fax

Practice location:
  • Phone: 720-649-0217
  • Fax:
Mailing address:
  • Phone: 720-649-0217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09929499
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: