Provider Demographics
NPI:1316512114
Name:GEORGE, LEIGH NICOLE
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:NICOLE
Last Name:GEORGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6624 SANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3964
Mailing Address - Country:US
Mailing Address - Phone:405-534-8223
Mailing Address - Fax:
Practice Address - Street 1:407 W SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-6133
Practice Address - Country:US
Practice Address - Phone:844-458-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty