Provider Demographics
NPI:1710206495
Name:LANDRETH, LEANN JEANETTE (CLINSCID)
Entity type:Individual
Prefix:
First Name:LEANN
Middle Name:JEANETTE
Last Name:LANDRETH
Suffix:
Gender:F
Credentials:CLINSCID
Other - Prefix:
Other - First Name:LEANN
Other - Middle Name:JEANETTE
Other - Last Name:LANDRETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CLINSCID
Mailing Address - Street 1:2115 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8007
Mailing Address - Country:US
Mailing Address - Phone:970-254-4872
Mailing Address - Fax:
Practice Address - Street 1:2115 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8007
Practice Address - Country:US
Practice Address - Phone:970-254-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007832235Z00000X
CO24465244235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003127569BMedicaid