Provider Demographics
NPI:1487082814
Name:ROBERTS CAULDRON, LESLEY
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:ROBERTS CAULDRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9494
Mailing Address - Fax:360-353-9440
Practice Address - Street 1:15455 65TH AVE S
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2534
Practice Address - Country:US
Practice Address - Phone:206-721-5170
Practice Address - Fax:363-575-1950
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 00007165101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health