Provider Demographics
NPI:1164709408
Name:MARCI M. LEVERIDGE, PH.D., PC
Entity Type:Organization
Organization Name:MARCI M. LEVERIDGE, PH.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-749-8559
Mailing Address - Street 1:3441 W MEMORIAL RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-7000
Mailing Address - Country:US
Mailing Address - Phone:405-749-8559
Mailing Address - Fax:405-749-8560
Practice Address - Street 1:3441 W MEMORIAL RD
Practice Address - Street 2:SUITE 5
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-7000
Practice Address - Country:US
Practice Address - Phone:405-749-8559
Practice Address - Fax:405-749-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK851103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK505804601Medicare UPIN