Provider Demographics
NPI:1104681642
Name:GWIN, LEORA (HS-BCP, CADC, CPS)
Entity type:Individual
Prefix:
First Name:LEORA
Middle Name:
Last Name:GWIN
Suffix:
Gender:F
Credentials:HS-BCP, CADC, CPS
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:GWIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:HS-BCP, CADC, CPS
Mailing Address - Street 1:1440 HARDING PL APT 616
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-0046
Mailing Address - Country:US
Mailing Address - Phone:882-861-2110
Mailing Address - Fax:
Practice Address - Street 1:2802 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3642
Practice Address - Country:US
Practice Address - Phone:452-259-3191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-22496101YA0400X
NCCPS-20143405300000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No405300000XOther Service ProvidersPrevention Professional