Provider Demographics
NPI:1821479122
Name:INDIVIDUAL PROVIDER
Entity Type:Organization
Organization Name:INDIVIDUAL PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:LETO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:970-618-6796
Mailing Address - Street 1:2800 KALMIA AVE
Mailing Address - Street 2:#A204
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1542
Mailing Address - Country:US
Mailing Address - Phone:970-618-6796
Mailing Address - Fax:
Practice Address - Street 1:4159 LOWELL BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-1658
Practice Address - Country:US
Practice Address - Phone:303-458-7220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0105326322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children