Provider Demographics
NPI:1891001137
Name:LEON, RAIDEL (CADC I, QMHA)
Entity Type:Individual
Prefix:
First Name:RAIDEL
Middle Name:
Last Name:LEON
Suffix:
Gender:M
Credentials:CADC I, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:503-200-3923
Mailing Address - Fax:503-241-7419
Practice Address - Street 1:231 SE 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1342
Practice Address - Country:US
Practice Address - Phone:503-546-9975
Practice Address - Fax:503-546-9976
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09-09-27101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator