Provider Demographics
NPI:1528028974
Name:LEAVITT, BLANDINE R (LMFT)
Entity Type:Individual
Prefix:
First Name:BLANDINE
Middle Name:R
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8120
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-0120
Mailing Address - Country:US
Mailing Address - Phone:541-776-7601
Mailing Address - Fax:541-776-3007
Practice Address - Street 1:1016 COURT ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-5728
Practice Address - Country:US
Practice Address - Phone:541-776-7601
Practice Address - Fax:541-776-3007
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0341106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist