Provider Demographics
NPI:1225372022
Name:LEONARD, MICHAEL R
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:LEONARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-2016
Mailing Address - Country:US
Mailing Address - Phone:580-298-5062
Mailing Address - Fax:580-298-9958
Practice Address - Street 1:1322 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2016
Practice Address - Country:US
Practice Address - Phone:580-298-5062
Practice Address - Fax:580-298-9958
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200111200AMedicaid