Provider Demographics
NPI:1104177963
Name:LEMING, LISA (MED)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LEMING
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 JOHN DR
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2005
Mailing Address - Country:US
Mailing Address - Phone:918-839-4999
Mailing Address - Fax:918-647-8121
Practice Address - Street 1:108 JOHN DR
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2005
Practice Address - Country:US
Practice Address - Phone:918-839-4999
Practice Address - Fax:918-647-8121
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200226970Medicaid