Provider Demographics
NPI:1851468516
Name:ROBERTS, LEISA CARROL (MSW)
Entity Type:Individual
Prefix:MS
First Name:LEISA
Middle Name:CARROL
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W MORROW RD
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-6549
Mailing Address - Country:US
Mailing Address - Phone:918-245-1328
Mailing Address - Fax:
Practice Address - Street 1:4720 S HARVARD AVE
Practice Address - Street 2:SUITE #207
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3048
Practice Address - Country:US
Practice Address - Phone:918-748-9868
Practice Address - Fax:918-748-9835
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 1041S0200X
OK44321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool