Provider Demographics
NPI:1245577576
Name:LEONARD, SHANTEL R
Entity type:Individual
Prefix:
First Name:SHANTEL
Middle Name:R
Last Name:LEONARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:MEAD
Mailing Address - State:OK
Mailing Address - Zip Code:73449-0048
Mailing Address - Country:US
Mailing Address - Phone:580-745-9610
Mailing Address - Fax:
Practice Address - Street 1:2601 NW EXPRESSWAY
Practice Address - Street 2:SUITE 101 E
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7272
Practice Address - Country:US
Practice Address - Phone:405-858-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid
OK100708380Medicaid