1659571230 NPI number — LESLIE ELVA PROUGH STAINBROOK QMHP

Table of content: LESLIE ELVA PROUGH STAINBROOK QMHP (NPI 1659571230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659571230 NPI number — LESLIE ELVA PROUGH STAINBROOK QMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAINBROOK
Provider First Name:
LESLIE
Provider Middle Name:
ELVA PROUGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
QMHP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PROUGH
Provider Other First Name:
LESLIE
Provider Other Middle Name:
ELVA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
QMHP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659571230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2421 LANCASTER DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97305-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-361-2642
Provider Business Mailing Address Fax Number:
503-588-5290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2421 LANCASTER DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97305-1220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-361-2642
Provider Business Practice Location Address Fax Number:
503-588-5290
Provider Enumeration Date:
07/20/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)