Provider Demographics
NPI:1104368539
Name:WATSON, LAKISHA
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:
Last Name:WATSON
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 1:650 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4429
Mailing Address - Country:US
Mailing Address - Phone:918-587-9471
Mailing Address - Fax:
Practice Address - Street 1:2325 S HARVARD AVE STE 400
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3306
Practice Address - Country:US
Practice Address - Phone:918-991-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator