Provider Demographics
NPI:1629418769
Name:LEVI, DIEDRA (BA)
Entity Type:Individual
Prefix:MS
First Name:DIEDRA
Middle Name:
Last Name:LEVI
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 46558
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72214-6558
Mailing Address - Country:US
Mailing Address - Phone:501-612-2599
Mailing Address - Fax:855-792-5483
Practice Address - Street 1:1860 E 15TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4611
Practice Address - Country:US
Practice Address - Phone:918-949-4430
Practice Address - Fax:918-949-4431
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK201819196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health