=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255684692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN GLADYS MCKINNEY PH.D., LSW, CSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2012
-----------------------------------------------------
Last Update Date | 02/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5131 S COLLEGE AVE
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80525-3968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-305-2399
-----------------------------------------------------
Fax | 970-236-9260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4217 WELLINGTON DR
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80526-5252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-556-2729
-----------------------------------------------------
Fax | 970-236-9260
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LSW-243
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW-9923084
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------