=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942624630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA JO LANDOLL MA, LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2014
-----------------------------------------------------
Last Update Date | 04/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2664 SACOMA CT
-----------------------------------------------------
City | GRAND JCT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81506-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-261-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2664 SACOMA CT
-----------------------------------------------------
City | GRAND JCT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81506-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-261-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | ACD.0000613
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0013950
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------