Provider Demographics
NPI:1861927089
Name:LESLIE RHEAULT, LPC
Entity type:Organization
Organization Name:LESLIE RHEAULT, LPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RHEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:541-499-1088
Mailing Address - Street 1:2191 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-4338
Mailing Address - Country:US
Mailing Address - Phone:541-499-1088
Mailing Address - Fax:
Practice Address - Street 1:2191 CANAL ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-4338
Practice Address - Country:US
Practice Address - Phone:541-499-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1655251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health