Provider Demographics
NPI:1780878694
Name:EAGLE TAIL, LEON DOUGLAS (MSW, CDP)
Entity type:Individual
Prefix:MR
First Name:LEON
Middle Name:DOUGLAS
Last Name:EAGLE TAIL
Suffix:
Gender:M
Credentials:MSW, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 N WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6812
Mailing Address - Country:US
Mailing Address - Phone:509-927-3837
Mailing Address - Fax:
Practice Address - Street 1:224 N WILLOW RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6812
Practice Address - Country:US
Practice Address - Phone:509-927-3837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00025859101Y00000X
WACP00004360101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor