Healthcare Provider Details

I. General information

NPI: 1164805107
Provider Name (Legal Business Name): REBECCA JILL LEITMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 24TH AVE S
SEATTLE WA
98144-4637
US

IV. Provider business mailing address

656 NW 81ST ST
SEATTLE WA
98117-4054
US

V. Phone/Fax

Practice location:
  • Phone: 206-382-5340
  • Fax:
Mailing address:
  • Phone: 914-471-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLW 60389096
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: