Provider Demographics
NPI:1255797460
Name:LEON, LATASHA (LADC-MH)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:LEON
Suffix:
Gender:F
Credentials:LADC-MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WHITE EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-8315
Mailing Address - Country:US
Mailing Address - Phone:580-304-3602
Mailing Address - Fax:
Practice Address - Street 1:200 WHITE EAGLE DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-8315
Practice Address - Country:US
Practice Address - Phone:580-304-2493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1446101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty