Provider Demographics
NPI:1093014391
Name:RHEAULT, LESLIE INGRID (MA, LPC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:INGRID
Last Name:RHEAULT
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 1:2191 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-4338
Mailing Address - Country:US
Mailing Address - Phone:541-499-1088
Mailing Address - Fax:
Practice Address - Street 1:2191 CANAL ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-4338
Practice Address - Country:US
Practice Address - Phone:541-499-1088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1655101YP2500X
OR4608066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional