Provider Demographics
NPI:1922331586
Name:TANNER, LEONA LILLIAN (LADC)
Entity Type:Individual
Prefix:MS
First Name:LEONA
Middle Name:LILLIAN
Last Name:TANNER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-2429
Mailing Address - Country:US
Mailing Address - Phone:918-367-1114
Mailing Address - Fax:918-367-1115
Practice Address - Street 1:109 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010-2429
Practice Address - Country:US
Practice Address - Phone:918-367-1114
Practice Address - Fax:918-367-1115
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X
OK1095101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor