Provider Demographics
NPI:1750571618
Name:LEAK, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:LEAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0615 SW PALATINE HILL RD
Mailing Address - Street 2:MSC 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7879
Mailing Address - Country:US
Mailing Address - Phone:503-535-1181
Mailing Address - Fax:
Practice Address - Street 1:0615 SW PALATINE HILL RD
Practice Address - Street 2:MSC 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-7879
Practice Address - Country:US
Practice Address - Phone:503-535-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist