Provider Demographics
NPI:1982229621
Name:DEFFKE, DONNA G
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:G
Last Name:DEFFKE
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 1:420 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1441
Mailing Address - Country:US
Mailing Address - Phone:303-834-9369
Mailing Address - Fax:
Practice Address - Street 1:420 21ST AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1441
Practice Address - Country:US
Practice Address - Phone:303-834-9369
Practice Address - Fax:303-834-9396
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0006995101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)