Provider Demographics
NPI:1043638448
Name:LEARY, RACHAEL MARBLE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:MARBLE
Last Name:LEARY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SW CENTURY DR STE 100-5038
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3557
Mailing Address - Country:US
Mailing Address - Phone:541-668-6141
Mailing Address - Fax:541-236-0332
Practice Address - Street 1:2424 SW PUMICE AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-6729
Practice Address - Country:US
Practice Address - Phone:541-668-6141
Practice Address - Fax:541-236-0332
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-12-20128101YA0400X
ORC6420101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043638448OtherNPI1
OR500672516Medicaid