Provider Demographics
NPI:1467911412
Name:FREDERICK, LEERISA
Entity Type:Individual
Prefix:
First Name:LEERISA
Middle Name:
Last Name:FREDERICK
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 1:416 S MUSTANG RD STE B
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-7314
Mailing Address - Country:US
Mailing Address - Phone:405-448-6163
Mailing Address - Fax:
Practice Address - Street 1:416 S MUSTANG RD STE B
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-7314
Practice Address - Country:US
Practice Address - Phone:405-494-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10584101Y00000X
OKLPCCANDIDATE10584101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor