Provider Demographics
NPI:1952875619
Name:SUSSO, LESLIE DAWN
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DAWN
Last Name:SUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBEKKA
Other - Middle Name:D
Other - Last Name:SUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CG
Mailing Address - Street 1:934 S GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:AIRWAY HEIGHTS
Mailing Address - State:WA
Mailing Address - Zip Code:99001-9030
Mailing Address - Country:US
Mailing Address - Phone:509-789-7614
Mailing Address - Fax:
Practice Address - Street 1:934 S GARFIELD RD
Practice Address - Street 2:
Practice Address - City:AIRWAY HEIGHTS
Practice Address - State:WA
Practice Address - Zip Code:99001-9030
Practice Address - Country:US
Practice Address - Phone:509-789-7614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60922467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)