Provider Demographics
NPI:1073832119
Name:LEA, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:LEA
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:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-0179
Mailing Address - Country:US
Mailing Address - Phone:918-967-4650
Mailing Address - Fax:918-967-4582
Practice Address - Street 1:101 W QUESENBURY AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-3613
Practice Address - Country:US
Practice Address - Phone:918-790-2653
Practice Address - Fax:918-790-2657
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker