Provider Demographics
NPI:1043794126
Name:LEONARD, SUSIE (CSWA)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:LEONARD
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 GATEWAY LOOP
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-7723
Mailing Address - Country:US
Mailing Address - Phone:541-654-8107
Mailing Address - Fax:
Practice Address - Street 1:1126 GATEWAY LOOP
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7723
Practice Address - Country:US
Practice Address - Phone:541-654-8107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA6012101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV02401-IOtherCERTIFIED ALCOHOL AND DRUG COUNSELOR-INTERN