Provider Demographics
NPI:1376369611
Name:LEGUIZAMON GRANT, TERESA ZEA (MA, LPCC, R-DMT)
Entity type:Individual
Prefix:
First Name:TERESA ZEA
Middle Name:
Last Name:LEGUIZAMON GRANT
Suffix:
Gender:F
Credentials:MA, LPCC, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 TERRY ST UNIT F
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5476
Mailing Address - Country:US
Mailing Address - Phone:415-320-4340
Mailing Address - Fax:
Practice Address - Street 1:1800 30TH ST STE 201N
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1026
Practice Address - Country:US
Practice Address - Phone:415-580-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225600000X
COLPCC.0022288101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist