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General NPI Number Information
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NPI Number | 1104681642
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Entity Type | Individual
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Provider Name | LEORA GWIN HS-BCP, CADC, CPS
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Gender | Female
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Dates
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Enumeration Date | 02/14/2024
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Last Update Date | 02/14/2024
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Provider Practice Location Address
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Address Line | 2802 BROADWAY
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City | EVERETT
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State | WA
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Zip | 98201-3642
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Country | US
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Telephone | 452-259-3191
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Fax |
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Provider Business Mailing Address
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Address Line | 1440 HARDING PL APT 616
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City | CHARLOTTE
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State | NC
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Zip | 28204-0046
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Country | US
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Telephone | 882-861-2110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CADC-22496
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License Number State |
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Taxonomy #2
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Taxonomy Code | 405300000X
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Taxonomy Name | Prevention Professional
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License Number | CPS-20143
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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