Provider Demographics
NPI:1346685989
Name:PERSLEY, DIANDRA LATRELL
Entity Type:Individual
Prefix:
First Name:DIANDRA
Middle Name:LATRELL
Last Name:PERSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANDRA
Other - Middle Name:LATRELL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2544 W FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-5125
Mailing Address - Country:US
Mailing Address - Phone:918-549-5227
Mailing Address - Fax:
Practice Address - Street 1:4636 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2908
Practice Address - Country:US
Practice Address - Phone:918-382-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health