Provider Demographics
NPI:1730673559
Name:GALLAWAY, LESLIE LOUISE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LOUISE
Last Name:GALLAWAY
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 1:724 S MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4660
Mailing Address - Country:US
Mailing Address - Phone:918-248-4340
Mailing Address - Fax:918-248-4345
Practice Address - Street 1:724 S MISSION ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4660
Practice Address - Country:US
Practice Address - Phone:918-248-4340
Practice Address - Fax:918-248-4345
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$Medicaid