Provider Demographics
NPI:1598095531
Name:GELLERT, LESLIE ANN (MSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:GELLERT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6274 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2674
Mailing Address - Country:US
Mailing Address - Phone:971-290-8458
Mailing Address - Fax:
Practice Address - Street 1:6274 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2674
Practice Address - Country:US
Practice Address - Phone:971-290-8458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
ORL53051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid
OR096511Medicaid
ORR0000WCJHTMedicare Oscar/Certification