Provider Demographics
NPI:1639494669
Name:GUST, LEESA (LMP)
Entity Type:Individual
Prefix:MISS
First Name:LEESA
Middle Name:
Last Name:GUST
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13264
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99213-3264
Mailing Address - Country:US
Mailing Address - Phone:509-990-8208
Mailing Address - Fax:
Practice Address - Street 1:15701 E SPRAGUE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-5019
Practice Address - Country:US
Practice Address - Phone:509-926-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024194174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist