Provider Demographics
NPI:1578186680
Name:LEITZELAR, LISA ANNE (LICSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:LEITZELAR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17823 25TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-3901
Mailing Address - Country:US
Mailing Address - Phone:206-948-3257
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-583-6578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW603418451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical