Healthcare Provider Details

I. General information

NPI: 1811910920
Provider Name (Legal Business Name): BRUCE A. LEESON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EVANS ARMY COMMUNITY HOSPITAL EMBEDDED BEHAVIORAL HEALTH TEAM 5, BLDG 1226
FT. CARSON CO
80913
US

IV. Provider business mailing address

611 E WILLAMETTE AVE
COLORADO SPRINGS CO
80903-3030
US

V. Phone/Fax

Practice location:
  • Phone: 719-503-7701
  • Fax: 719-526-8770
Mailing address:
  • Phone: 816-304-4061
  • Fax: 719-526-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY RO 269
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: