Healthcare Provider Details

I. General information

NPI: 1811537277
Provider Name (Legal Business Name): DWIGHT AUSTIN SERGIO DE LEON CP61215033
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 W GARDNER AVE
SPOKANE WA
99201-2059
US

IV. Provider business mailing address

PO BOX 10157
SPOKANE WA
99209-1157
US

V. Phone/Fax

Practice location:
  • Phone: 509-503-6010
  • Fax: 509-474-9612
Mailing address:
  • Phone: 503-702-8454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61215033
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: