Provider Demographics
NPI:1649382623
Name:WAITE, SUE LESLIE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:LESLIE
Last Name:WAITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 SE PINE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3130
Mailing Address - Country:US
Mailing Address - Phone:541-672-5100
Mailing Address - Fax:541-672-5100
Practice Address - Street 1:270 SE PINE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3130
Practice Address - Country:US
Practice Address - Phone:541-672-5100
Practice Address - Fax:541-672-5100
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1135101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health