Provider Demographics
NPI:1164576559
Name:MEDOFF, LEONARD B (PHD)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:B
Last Name:MEDOFF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 E ELIZABETH BLDG 6
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524
Mailing Address - Country:US
Mailing Address - Phone:970-484-0663
Mailing Address - Fax:970-221-2446
Practice Address - Street 1:1217 E ELIZABETH BLDG 6
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-484-0663
Practice Address - Fax:970-221-2446
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical