Provider Demographics
NPI:1265527576
Name:BROST, LESLIE GAMBILL (PSYD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:GAMBILL
Last Name:BROST
Suffix:
Gender:F
Credentials:PSYD
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 2110
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-2110
Mailing Address - Country:US
Mailing Address - Phone:509-276-5644
Mailing Address - Fax:509-276-5644
Practice Address - Street 1:110 W CRAWFORD ST STE F
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006
Practice Address - Country:US
Practice Address - Phone:509-276-5644
Practice Address - Fax:509-780-4394
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002703103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent