Provider Demographics
NPI:1437874674
Name:WHEELER, LEEZETTE MARIE
Entity Type:Individual
Prefix:
First Name:LEEZETTE
Middle Name:MARIE
Last Name:WHEELER
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 1:12439 SE 160TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-4720
Mailing Address - Country:US
Mailing Address - Phone:425-919-5314
Mailing Address - Fax:
Practice Address - Street 1:1445 NW MALL ST STE 2
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-7900
Practice Address - Country:US
Practice Address - Phone:206-380-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician