Provider Demographics
NPI:1285054072
Name:LEYPOLDT, ANASTASIA GRACE
Entity type:Individual
Prefix:MS
First Name:ANASTASIA
Middle Name:GRACE
Last Name:LEYPOLDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 MCPHERSON ST
Mailing Address - Street 2:STE 2
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-3482
Mailing Address - Country:US
Mailing Address - Phone:541-751-2508
Mailing Address - Fax:541-751-2661
Practice Address - Street 1:1975 MCPHERSON ST STE 2
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-3482
Practice Address - Country:US
Practice Address - Phone:541-751-2508
Practice Address - Fax:541-751-2661
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3594101YP2500X
NE2066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health