Provider Demographics
NPI:1467778563
Name:BLACK, LEILANI R
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:R
Last Name:BLACK
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 1:3719 S INDIANAPOLIS AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7010 S YALE AVE STE 215
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5743
Practice Address - Country:US
Practice Address - Phone:918-492-2554
Practice Address - Fax:918-494-9870
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker