Provider Demographics
NPI:1659410330
Name:LATTERELL, LEANNE KAY (LICENSED CLINICAL SO)
Entity Type:Individual
Prefix:MS
First Name:LEANNE
Middle Name:KAY
Last Name:LATTERELL
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1724
Mailing Address - Country:US
Mailing Address - Phone:541-504-5745
Mailing Address - Fax:
Practice Address - Street 1:203 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1724
Practice Address - Country:US
Practice Address - Phone:541-504-5745
Practice Address - Fax:541-504-5805
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR133656Medicare ID - Type Unspecified