Provider Demographics
NPI:1609607886
Name:TWEEDY, LEATHA FAYANN
Entity type:Individual
Prefix:
First Name:LEATHA
Middle Name:FAYANN
Last Name:TWEEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4363 VAL VISTA AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-2777
Mailing Address - Country:US
Mailing Address - Phone:971-239-7368
Mailing Address - Fax:
Practice Address - Street 1:2645 PORTLAND RD NE STE 120
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0200
Practice Address - Country:US
Practice Address - Phone:503-390-5637
Practice Address - Fax:503-393-3135
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor