Provider Demographics
NPI:1073278875
Name:WIEDENMAN, HALEY LUCILLE (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:LUCILLE
Last Name:WIEDENMAN
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 NEW MEXICO AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4722
Mailing Address - Country:US
Mailing Address - Phone:720-480-0710
Mailing Address - Fax:
Practice Address - Street 1:2707 NEW MEXICO AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4722
Practice Address - Country:US
Practice Address - Phone:720-480-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0019616101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0018612Medicaid