Provider Demographics
NPI:1598054363
Name:TRUSSELL, LEONE (MA)
Entity Type:Individual
Prefix:
First Name:LEONE
Middle Name:
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 FRONT ST N
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2914
Mailing Address - Country:US
Mailing Address - Phone:425-392-6367
Mailing Address - Fax:425-391-4971
Practice Address - Street 1:414 FRONT ST N
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2914
Practice Address - Country:US
Practice Address - Phone:425-392-6367
Practice Address - Fax:425-391-4971
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC 60203399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA910672501Medicaid