Provider Demographics
NPI:1760940977
Name:BROCKMAN, LESLIE ANNE (LICSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNE
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ANNE
Other - Last Name:VILHAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1521 E ILLINOIS AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-5147
Mailing Address - Country:US
Mailing Address - Phone:509-564-9363
Mailing Address - Fax:
Practice Address - Street 1:1521 E ILLINOIS AVE STE 104
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-5147
Practice Address - Country:US
Practice Address - Phone:509-564-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW614110161041C0700X
WACG60939370390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program