Provider Demographics
NPI:1770901183
Name:GLEASON, MANDIE L (LMT)
Entity type:Individual
Prefix:MS
First Name:MANDIE
Middle Name:L
Last Name:GLEASON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 IOWA DR UNIT 101
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4766
Mailing Address - Country:US
Mailing Address - Phone:505-231-0984
Mailing Address - Fax:
Practice Address - Street 1:420 S HOWES ST
Practice Address - Street 2:SUITE A-105
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2871
Practice Address - Country:US
Practice Address - Phone:505-231-0984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCOMT 13577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist