Provider Demographics
NPI:1831115450
Name:RITCHIE, LIESA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LIESA
Middle Name:MARIE
Last Name:RITCHIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18522 E PERSIMMON LN
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-8338
Mailing Address - Country:US
Mailing Address - Phone:918-812-3932
Mailing Address - Fax:
Practice Address - Street 1:18522 E PERSIMMON LN
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-8338
Practice Address - Country:US
Practice Address - Phone:918-812-3932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200030100AOtherEPSDT
OK200030100BMedicaid