Provider Demographics
NPI:1194425397
Name:WEDGLE, LEILANI ANISE (RBT)
Entity type:Individual
Prefix:
First Name:LEILANI
Middle Name:ANISE
Last Name:WEDGLE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 SAN MARCOS DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-1242
Mailing Address - Country:US
Mailing Address - Phone:719-447-7938
Mailing Address - Fax:
Practice Address - Street 1:3595 E FOUNTAIN BLVD STE 145
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-1791
Practice Address - Country:US
Practice Address - Phone:254-630-1578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
CO17-093-7386106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician