Provider Demographics
NPI:1235460106
Name:MCKENZIE, LEUSO
Entity Type:Individual
Prefix:MR
First Name:LEUSO
Middle Name:
Last Name:MCKENZIE
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 1:13818 NE 62ND ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5952
Mailing Address - Country:US
Mailing Address - Phone:206-393-8404
Mailing Address - Fax:
Practice Address - Street 1:1500 NE IRVING ST
Practice Address - Street 2:SUITE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2243
Practice Address - Country:US
Practice Address - Phone:503-258-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-16
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker