Healthcare Provider Details

I. General information

NPI: 1033625645
Provider Name (Legal Business Name): LEETTA RAE KLINK LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5446 N ACADEMY BLVD
COLORADO SPRINGS CO
80918-3644
US

IV. Provider business mailing address

7898 BLACK WALNUT DR
COLORADO SPRINGS CO
80920-2207
US

V. Phone/Fax

Practice location:
  • Phone: 719-598-5555
  • Fax: 719-388-2030
Mailing address:
  • Phone: 415-425-3804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0000951
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLSW.0009925776
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: