Provider Demographics
NPI:1124370549
Name:BURROUGH, LAKISHA S
Entity Type:Individual
Prefix:MS
First Name:LAKISHA
Middle Name:S
Last Name:BURROUGH
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 1:401 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-3208
Mailing Address - Country:US
Mailing Address - Phone:405-600-5154
Mailing Address - Fax:
Practice Address - Street 1:401 PINEHURST DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-3208
Practice Address - Country:US
Practice Address - Phone:405-600-5154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKKO81319431103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOC4184OtherOTHER INS