Provider Demographics
NPI:1780998864
Name:LESLIE DEMOSS, LORA MAE (LCSW)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:MAE
Last Name:LESLIE DEMOSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LORA
Other - Middle Name:MAE
Other - Last Name:LESLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3015 E SKELLY DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6317
Mailing Address - Country:US
Mailing Address - Phone:918-712-0859
Mailing Address - Fax:918-388-9708
Practice Address - Street 1:3015 E SKELLY DR
Practice Address - Street 2:SUITE 103
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6317
Practice Address - Country:US
Practice Address - Phone:918-712-0859
Practice Address - Fax:918-388-9708
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746170Medicaid