Provider Demographics
NPI:1235563719
Name:LEISCHNER, GERALD E
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:E
Last Name:LEISCHNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6217 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5648
Mailing Address - Country:US
Mailing Address - Phone:405-728-0962
Mailing Address - Fax:
Practice Address - Street 1:5401 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73179-7602
Practice Address - Country:US
Practice Address - Phone:405-681-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)