Provider Demographics
NPI:1881220440
Name:LEEZER, GRETCHEN
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:LEEZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5609
Mailing Address - Country:US
Mailing Address - Phone:815-979-7005
Mailing Address - Fax:
Practice Address - Street 1:3050 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3154
Practice Address - Country:US
Practice Address - Phone:815-979-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000683101YA0400X
COLPC.0012825101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)