Provider Demographics
NPI:1396012357
Name:LEERDAM, EDITH MARIA
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:MARIA
Last Name:LEERDAM
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 1:1217 W KNOXVILLE ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8434
Mailing Address - Country:US
Mailing Address - Phone:918-258-1857
Mailing Address - Fax:
Practice Address - Street 1:1217 W KNOXVILLE ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8434
Practice Address - Country:US
Practice Address - Phone:918-258-1857
Practice Address - Fax:918-258-6987
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor