Provider Demographics
NPI:1790439768
Name:LEU, SHANE BRANDENBURG (BHCM1)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:BRANDENBURG
Last Name:LEU
Suffix:
Gender:M
Credentials:BHCM1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 E ADMIRAL PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74110-5436
Mailing Address - Country:US
Mailing Address - Phone:918-835-3017
Mailing Address - Fax:918-836-0358
Practice Address - Street 1:2727 E ADMIRAL PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74110-5436
Practice Address - Country:US
Practice Address - Phone:918-835-3017
Practice Address - Fax:918-836-0358
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator