Provider Demographics
NPI:1164002887
Name:LENZ, TREVOR JEROME (BS, CAS, RC)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:JEROME
Last Name:LENZ
Suffix:
Gender:M
Credentials:BS, CAS, RC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 ROSS DR APT J26
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1178
Mailing Address - Country:US
Mailing Address - Phone:720-240-1564
Mailing Address - Fax:
Practice Address - Street 1:3400 W 16TH ST STE P
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6871
Practice Address - Country:US
Practice Address - Phone:970-978-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 175T00000X
COACC.0998578101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15152227OtherCAQH