Provider Demographics
NPI:1477684835
Name:LEITZEL, MARK S (LCPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:S
Last Name:LEITZEL
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10462
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-3462
Mailing Address - Country:US
Mailing Address - Phone:406-756-0887
Mailing Address - Fax:
Practice Address - Street 1:40 2ND STREET EAST #212
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-0000
Practice Address - Country:US
Practice Address - Phone:406-756-0887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT920101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0252671Medicaid
MT744473OtherBLUE CROSS BLUE SHIELD