Provider Demographics
NPI:1427708171
Name:LELAND ST. CHARLES, PSYCHOLOGIST, LLC
Entity type:Organization
Organization Name:LELAND ST. CHARLES, PSYCHOLOGIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST, OWNER, SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:
Authorized Official - Last Name:ST CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-755-8808
Mailing Address - Street 1:8415 SE 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-8613
Mailing Address - Country:US
Mailing Address - Phone:415-710-6141
Mailing Address - Fax:
Practice Address - Street 1:1210 SE OAK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1427
Practice Address - Country:US
Practice Address - Phone:503-755-8808
Practice Address - Fax:971-339-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-25
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health