Provider Demographics
NPI:1659571230
Name:STAINBROOK, LESLIE ELVA PROUGH (QMHP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ELVA PROUGH
Last Name:STAINBROOK
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ELVA
Other - Last Name:PROUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHP
Mailing Address - Street 1:2421 LANCASTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1220
Mailing Address - Country:US
Mailing Address - Phone:503-361-2642
Mailing Address - Fax:503-588-5290
Practice Address - Street 1:2421 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1220
Practice Address - Country:US
Practice Address - Phone:503-361-2642
Practice Address - Fax:503-588-5290
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health