Healthcare Provider Details

I. General information

NPI: 1013626316
Provider Name (Legal Business Name): KATIE ELIZABETH LEAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE ELIZABETH HODGES

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 13TH ST
BAKER CITY OR
97814-1340
US

IV. Provider business mailing address

3425 13TH ST
BAKER CITY OR
97814-1340
US

V. Phone/Fax

Practice location:
  • Phone: 541-523-7400
  • Fax: 541-523-7400
Mailing address:
  • Phone: 541-523-7400
  • Fax: 541-523-4927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number24-QMHA-R-5809
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-22-2055
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: