Healthcare Provider Details

I. General information

NPI: 1669391348
Provider Name (Legal Business Name): LESLIE DOMEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 HAWTHORNE AVE SE STE 120
SALEM OR
97301-6684
US

IV. Provider business mailing address

660 HAWTHORNE AVE SE STE 120
SALEM OR
97301-6684
US

V. Phone/Fax

Practice location:
  • Phone: 503-577-7753
  • Fax: 503-616-3804
Mailing address:
  • Phone: 503-577-7753
  • Fax: 503-616-3804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: