Provider Demographics
NPI:1770254252
Name:LEISS, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LEISS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21471 HOWARD AVE NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9104
Mailing Address - Country:US
Mailing Address - Phone:806-567-5364
Mailing Address - Fax:
Practice Address - Street 1:19351 8TH AVE NE STE 141
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7087
Practice Address - Country:US
Practice Address - Phone:360-876-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61099384101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)