Provider Demographics
NPI:1811910920
Name:LEESON, BRUCE A (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:LEESON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:611 E WILLAMETTE AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3030
Mailing Address - Country:US
Mailing Address - Phone:816-304-4061
Mailing Address - Fax:719-526-8770
Practice Address - Street 1:EVANS ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:EMBEDDED BEHAVIORAL HEALTH TEAM 5, BLDG 1226
Practice Address - City:FT. CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-503-7701
Practice Address - Fax:719-526-8770
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY RO 269103TC0700X
103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
50331OtherNATIONAL REGISTER OF HEALTHCARE PROVIDERS IN PSYCHOLOGY