Provider Demographics
NPI:1811537277
Name:DE LEON, DWIGHT AUSTIN SERGIO (CP61215033)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:AUSTIN SERGIO
Last Name:DE LEON
Suffix:
Gender:M
Credentials:CP61215033
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 10157
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99209-1157
Mailing Address - Country:US
Mailing Address - Phone:503-702-8454
Mailing Address - Fax:
Practice Address - Street 1:1302 W GARDNER AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2059
Practice Address - Country:US
Practice Address - Phone:509-503-6010
Practice Address - Fax:509-474-9612
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61215033101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)