Provider Demographics
NPI:1316580681
Name:WILLEY, BREANNE (LPC, NCC, CCM)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:WILLEY
Suffix:
Gender:F
Credentials:LPC, NCC, CCM
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, NCC
Mailing Address - Street 1:8756 DEL RIO RD
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-6799
Mailing Address - Country:US
Mailing Address - Phone:719-659-1915
Mailing Address - Fax:
Practice Address - Street 1:7560 RANGEWOOD DR STE 210
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-2100
Practice Address - Country:US
Practice Address - Phone:719-659-1915
Practice Address - Fax:888-425-0383
Is Sole Proprietor?:No
Enumeration Date:2019-10-19
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17649101YP2500X
CO6225101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1316580681Medicaid