Provider Demographics
NPI:1922673524
Name:BANFILL, LEIGH (CSWA, QMHP)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:BANFILL
Suffix:
Gender:M
Credentials:CSWA, QMHP
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 82935
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0935
Mailing Address - Country:US
Mailing Address - Phone:971-236-1326
Mailing Address - Fax:
Practice Address - Street 1:1132 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1703
Practice Address - Country:US
Practice Address - Phone:503-535-3860
Practice Address - Fax:503-223-6837
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA55661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical