Healthcare Provider Details

I. General information

NPI: 1285361527
Provider Name (Legal Business Name): DAVID LESLIE VANDIEST M.A., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NE HOOD AVE STE 240
GRESHAM OR
97030-7347
US

IV. Provider business mailing address

501 NE HOOD AVE STE 240
GRESHAM OR
97030-7347
US

V. Phone/Fax

Practice location:
  • Phone: 971-276-5675
  • Fax:
Mailing address:
  • Phone: 971-276-5675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC6924
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: