Basic Information
| Provider Information | |||||||||
| NPI: | 1396877692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAISNER | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAKER | ||||||||
| OtherFirstName: | MANDY | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSY PH D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3225 INDEPENDENCE RD | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812129380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192752351 | ||||||||
| FaxNumber: | 7192699386 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | LEADVILLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804613921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194860985 | ||||||||
| FaxNumber: | 7194860986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5826 | CO | N | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 101YP2500X | 5826 | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.