Provider Demographics
NPI:1588955173
Name:VILLELA, LESLIE (LMT, HHP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:VILLELA
Suffix:
Gender:F
Credentials:LMT, HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4975 SW LOMBARD AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2936
Mailing Address - Country:US
Mailing Address - Phone:760-672-0033
Mailing Address - Fax:
Practice Address - Street 1:2534 NW VAUGHN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2552
Practice Address - Country:US
Practice Address - Phone:503-477-8881
Practice Address - Fax:503-719-4695
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15218225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist