Provider Demographics
NPI:1881656494
Name:RILEY, LESLIE ROSE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ROSE
Last Name:RILEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12906 E 106TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-5909
Mailing Address - Country:US
Mailing Address - Phone:918-240-9380
Mailing Address - Fax:918-376-4586
Practice Address - Street 1:12906 E 106TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-5909
Practice Address - Country:US
Practice Address - Phone:918-240-9380
Practice Address - Fax:918-376-4586
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR03-9P103TC0700X
OK1215103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200579150AMedicaid
OK403453ZNJKMedicare PIN