Provider Demographics
NPI:1700666799
Name:WILLSON, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WILLSON
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 1:300 W CHEROKEE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5600
Mailing Address - Country:US
Mailing Address - Phone:580-340-7235
Mailing Address - Fax:
Practice Address - Street 1:300 W CHEROKEE AVE STE 102
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5600
Practice Address - Country:US
Practice Address - Phone:580-340-7235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)