Provider Demographics
NPI:1679876429
Name:LEYBA, MICHAEL EDWARD (MA,LPC,CACIII)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:LEYBA
Suffix:
Gender:M
Credentials:MA,LPC,CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 E. 13TH ST.
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001
Mailing Address - Country:US
Mailing Address - Phone:719-546-6666
Mailing Address - Fax:719-543-7764
Practice Address - Street 1:4 MONTEBELLO RD.
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001
Practice Address - Country:US
Practice Address - Phone:719-546-6666
Practice Address - Fax:719-543-7764
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO506324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility