Healthcare Provider Details

I. General information

NPI: 1154886364
Provider Name (Legal Business Name): LESLIE YEARGERS LMFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5627 SE WOODSTOCK BLVD
PORTLAND OR
97206-6830
US

IV. Provider business mailing address

635 SW COLONY DR
PORTLAND OR
97219-7764
US

V. Phone/Fax

Practice location:
  • Phone: 503-298-5051
  • Fax:
Mailing address:
  • Phone: 503-892-2476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberR5549
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: