Provider Demographics
NPI:1396591657
Name:MANTRAVADI, KATHRYN 'KC' (MA, MFTC, LPCC)
Entity type:Individual
Prefix:
First Name:KATHRYN 'KC'
Middle Name:
Last Name:MANTRAVADI
Suffix:
Gender:F
Credentials:MA, MFTC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6433 JULES DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3865
Mailing Address - Country:US
Mailing Address - Phone:719-358-1174
Mailing Address - Fax:
Practice Address - Street 1:7710 N UNION BLVD STE F
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-4030
Practice Address - Country:US
Practice Address - Phone:719-358-1174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-27
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0014560106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist