Healthcare Provider Details

I. General information

NPI: 1104681642
Provider Name (Legal Business Name): LEORA GWIN HS-BCP, CADC, CPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LEE GWIN HS-BCP, CADC, CPS

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 BROADWAY
EVERETT WA
98201-3642
US

IV. Provider business mailing address

1440 HARDING PL APT 616
CHARLOTTE NC
28204-0046
US

V. Phone/Fax

Practice location:
  • Phone: 452-259-3191
  • Fax:
Mailing address:
  • Phone: 882-861-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-22496
License Number State
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberCPS-20143
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: