Provider Demographics
NPI:1609600402
Name:GRONDIN, LEEANNA MARIE
Entity type:Individual
Prefix:
First Name:LEEANNA
Middle Name:MARIE
Last Name:GRONDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 796
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-0796
Mailing Address - Country:US
Mailing Address - Phone:580-319-5770
Mailing Address - Fax:580-319-7086
Practice Address - Street 1:243 COOK AVE
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3930
Practice Address - Country:US
Practice Address - Phone:580-319-5770
Practice Address - Fax:580-319-7086
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRBT-24-372396106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician