Provider Demographics
NPI:1134642952
Name:POTTEBAUM, LESLIE
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:POTTEBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16155 W 74TH DR
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80007-7828
Mailing Address - Country:US
Mailing Address - Phone:303-912-1111
Mailing Address - Fax:
Practice Address - Street 1:16155 W 74TH DR
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80007-7828
Practice Address - Country:US
Practice Address - Phone:303-912-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities