Healthcare Provider Details

I. General information

NPI: 1336201730
Provider Name (Legal Business Name): SANDIE LEISTIKO MSW, MHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 CENTRAL AVE S SUITE 113
KENT WA
98032-7433
US

IV. Provider business mailing address

1600 E OLIVE ST SEATTLE MENTAL HEALTH
SEATTLE WA
98122-2735
US

V. Phone/Fax

Practice location:
  • Phone: 253-876-7620
  • Fax: 253-876-7621
Mailing address:
  • Phone: 206-302-2200
  • Fax: 206-302-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberRC00042775
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60073152
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: