Provider Demographics
NPI:1942624630
Name:LANDOLL, DEBRA JO (MA, LAC)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JO
Last Name:LANDOLL
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:JO
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10700
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-5517
Mailing Address - Country:US
Mailing Address - Phone:970-254-2642
Mailing Address - Fax:
Practice Address - Street 1:1120 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6129
Practice Address - Country:US
Practice Address - Phone:970-241-6011
Practice Address - Fax:970-241-4650
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ACD.0000613101YA0400X
COLPC.0013950101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)