=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538875778
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE WILLIAMS PSS, IPS, CHW, QMHA-
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2023
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2584 NW KINGWOOD AVE # C103
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97756-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-550-0253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2584 NW KINGWOOD AVE # C103
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97756-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-550-0253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | THW000105992
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------