Provider Demographics
NPI:1154981769
Name:THIELK, KELLY LEIGH (LCSW, CADC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEIGH
Last Name:THIELK
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEIGH
Other - Last Name:TODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3475 YULE TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-1243
Mailing Address - Country:US
Mailing Address - Phone:331-725-1878
Mailing Address - Fax:
Practice Address - Street 1:300 E HORSETOOTH RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3154
Practice Address - Country:US
Practice Address - Phone:331-725-1878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL32880101YA0400X
IL1490209031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty