Provider Demographics
NPI:1770879660
Name:STOVALL LEBLANC, LETISHA LYNN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LETISHA
Middle Name:LYNN
Last Name:STOVALL LEBLANC
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LETISHA
Other - Middle Name:LYNN
Other - Last Name:STOVALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12860 GUN CLUB RD
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-8908
Mailing Address - Country:US
Mailing Address - Phone:270-314-4486
Mailing Address - Fax:918-518-7402
Practice Address - Street 1:418 E 2ND ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-3302
Practice Address - Country:US
Practice Address - Phone:918-268-6444
Practice Address - Fax:918-518-7402
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3763104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker