Provider Demographics
NPI:1225575772
Name:BAUSCH, LEISA ANN
Entity type:Individual
Prefix:MS
First Name:LEISA
Middle Name:ANN
Last Name:BAUSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEISA
Other - Middle Name:ANN
Other - Last Name:RAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1202 N WILLOW DR
Mailing Address - Street 2:UNIT A
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017
Mailing Address - Country:US
Mailing Address - Phone:918-629-8407
Mailing Address - Fax:
Practice Address - Street 1:11740 E 21ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129
Practice Address - Country:US
Practice Address - Phone:918-437-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst