Provider Demographics
NPI:1437799061
Name:BETTENCOURT, LESLIE GILDERSLEEVE (RD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:GILDERSLEEVE
Last Name:BETTENCOURT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ROXANNE
Other - Last Name:GILDERSLEEVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2981 NW 110TH TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-4662
Mailing Address - Country:US
Mailing Address - Phone:610-392-8731
Mailing Address - Fax:
Practice Address - Street 1:9427 SW BARNES RD STE 390
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6652
Practice Address - Country:US
Practice Address - Phone:503-215-7230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-11
Last Update Date:2020-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10187701133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered