Provider Demographics
NPI:1154886364
Name:YEARGERS, LESLIE (LMFT INTERN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:YEARGERS
Suffix:
Gender:F
Credentials:LMFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 SW COLONY DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7764
Mailing Address - Country:US
Mailing Address - Phone:503-892-2476
Mailing Address - Fax:
Practice Address - Street 1:5627 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6830
Practice Address - Country:US
Practice Address - Phone:503-298-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5549101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor