Provider Demographics
NPI:1134586449
Name:LEROY, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:LEROY
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:PO BOX 21542
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-4542
Mailing Address - Country:US
Mailing Address - Phone:720-346-1401
Mailing Address - Fax:
Practice Address - Street 1:5412 IDYLWILD TRL
Practice Address - Street 2:#100
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3523
Practice Address - Country:US
Practice Address - Phone:720-924-7559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0012692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional