Provider Demographics
NPI:1174824916
Name:BROADHEAD, LESLIE (LMFT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BROADHEAD
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 S DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5270
Mailing Address - Country:US
Mailing Address - Phone:405-441-1996
Mailing Address - Fax:405-455-5379
Practice Address - Street 1:1390 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5270
Practice Address - Country:US
Practice Address - Phone:405-441-1996
Practice Address - Fax:405-455-5379
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1114106H00000X
KS1167106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist