Basic Information
| Provider Information | |||||||||
| NPI: | 1326377847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIEZWAAG | ||||||||
| FirstName: | LEAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 SE JACKSON ST | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974704989 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 612 SE JACKSON ST | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974704989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414646455 | ||||||||
| FaxNumber: | 5414646457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2009 | ||||||||
| LastUpdateDate: | 12/11/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.