Provider Demographics
NPI:1588098859
Name:LEAVENWORTH, BRIAN
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:LEAVENWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40823 RODGERS MOUNTAIN LOOP
Mailing Address - Street 2:
Mailing Address - City:SCIO
Mailing Address - State:OR
Mailing Address - Zip Code:97374-9359
Mailing Address - Country:US
Mailing Address - Phone:541-990-3384
Mailing Address - Fax:503-394-4135
Practice Address - Street 1:40823 RODGERS MOUNTAIN LOOP
Practice Address - Street 2:
Practice Address - City:SCIO
Practice Address - State:OR
Practice Address - Zip Code:97374-9359
Practice Address - Country:US
Practice Address - Phone:541-990-3384
Practice Address - Fax:503-394-4135
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst