Healthcare Provider Details

I. General information

NPI: 1235493743
Provider Name (Legal Business Name): KATHLEEN SUZANNE LEAVITT M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR SUITE 310
GRESHAM OR
97030-3770
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282-0819
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax:
Mailing address:
  • Phone: 503-233-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: