Provider Demographics
NPI:1356881106
Name:WORTHAM, LESIA
Entity type:Individual
Prefix:
First Name:LESIA
Middle Name:
Last Name:WORTHAM
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 1:242 SHADY OAK GRV
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-1662
Mailing Address - Country:US
Mailing Address - Phone:719-306-8677
Mailing Address - Fax:
Practice Address - Street 1:112 IOWA AVE
Practice Address - Street 2:#4
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5930
Practice Address - Country:US
Practice Address - Phone:719-358-7338
Practice Address - Fax:844-273-2340
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0007973101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)