Provider Demographics
NPI:1225658560
Name:RYAN, LESLIE (MS, QMHA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92118 CAPE ARAGO HWY
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-8743
Mailing Address - Country:US
Mailing Address - Phone:509-679-1817
Mailing Address - Fax:
Practice Address - Street 1:377 LACLAIR ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-4709
Practice Address - Country:US
Practice Address - Phone:541-756-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist