Provider Demographics
NPI:1700918836
Name:TERRY, LEONARD (MBS)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:TERRY
Suffix:
Gender:M
Credentials:MBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 NW GAYE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-8238
Mailing Address - Country:US
Mailing Address - Phone:580-924-6363
Mailing Address - Fax:580-924-0379
Practice Address - Street 1:1204 NW GAYE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-8238
Practice Address - Country:US
Practice Address - Phone:580-924-6363
Practice Address - Fax:580-924-0379
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1807101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional