Provider Demographics
NPI:1760959290
Name:FLEEK, CONSWAYLO ANN (CDPT)
Entity Type:Individual
Prefix:MRS
First Name:CONSWAYLO
Middle Name:ANN
Last Name:FLEEK
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-2875
Mailing Address - Country:US
Mailing Address - Phone:509-248-1800
Mailing Address - Fax:
Practice Address - Street 1:120 S. 3RD AVE.
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901
Practice Address - Country:US
Practice Address - Phone:509-248-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60710253101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0755984Medicaid