Provider Demographics
NPI:1528201019
Name:KANNENBERG, RAND LESLIE (RETIRED - EXPIRED)
Entity Type:Individual
Prefix:
First Name:RAND
Middle Name:LESLIE
Last Name:KANNENBERG
Suffix:
Gender:M
Credentials:RETIRED - EXPIRED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7475 W 5TH AVE
Mailing Address - Street 2:150
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-1649
Mailing Address - Country:US
Mailing Address - Phone:303-232-0767
Mailing Address - Fax:303-232-0767
Practice Address - Street 1:7475 W 5TH AVE
Practice Address - Street 2:150
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-1649
Practice Address - Country:US
Practice Address - Phone:303-232-0767
Practice Address - Fax:303-232-0767
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD37101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)