Provider Demographics
NPI:1538756531
Name:O'DONOGHUE, LESLIE (LMHCA, LPC INTERN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:O'DONOGHUE
Suffix:
Gender:F
Credentials:LMHCA, LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105D 15TH AVE # 477
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3080
Mailing Address - Country:US
Mailing Address - Phone:360-560-0615
Mailing Address - Fax:
Practice Address - Street 1:513 E A ST
Practice Address - Street 2:
Practice Address - City:RAINIER
Practice Address - State:OR
Practice Address - Zip Code:97048-3124
Practice Address - Country:US
Practice Address - Phone:503-432-5053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61086371101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor