Provider Demographics
NPI:1689107070
Name:SPROUTS CHILD DEVELOPMENT INITIATIVE, INC.
Entity Type:Organization
Organization Name:SPROUTS CHILD DEVELOPMENT INITIATIVE, INC.
Other - Org Name:SPROUTS CHILD DEVELOPMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:BAKER
Authorized Official - Last Name:GUDGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MHR
Authorized Official - Phone:918-289-9387
Mailing Address - Street 1:5840 S MEMORIAL DR STE 111
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-9006
Mailing Address - Country:US
Mailing Address - Phone:918-699-4250
Mailing Address - Fax:918-831-7290
Practice Address - Street 1:5840 S MEMORIAL DR STE 111
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9006
Practice Address - Country:US
Practice Address - Phone:918-699-4250
Practice Address - Fax:918-831-7290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty