Provider Demographics
NPI:1942624630
Name:LANDOLL, DEBRA JO (MA, LAC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:JO
Last Name:LANDOLL
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:JO
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2664 SACOMA CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JCT
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1834
Mailing Address - Country:US
Mailing Address - Phone:970-261-5254
Mailing Address - Fax:
Practice Address - Street 1:2664 SACOMA CT
Practice Address - Street 2:
Practice Address - City:GRAND JCT
Practice Address - State:CO
Practice Address - Zip Code:81506-1834
Practice Address - Country:US
Practice Address - Phone:970-261-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000613101YA0400X
CO0013950101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)