Provider Demographics
NPI:1396167060
Name:PHANEUF-REYNOLDS, LEESA M (MA, MSW, LSWAIC)
Entity type:Individual
Prefix:MS
First Name:LEESA
Middle Name:M
Last Name:PHANEUF-REYNOLDS
Suffix:
Gender:F
Credentials:MA, MSW, LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W MAIN ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2872
Mailing Address - Country:US
Mailing Address - Phone:509-460-7206
Mailing Address - Fax:
Practice Address - Street 1:30 W MAIN ST
Practice Address - Street 2:SUITE 305
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2872
Practice Address - Country:US
Practice Address - Phone:509-460-7206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-14
Last Update Date:2016-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60412135101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health