Provider Demographics
NPI:1366780017
Name:LEA, ANDREA MICHAEL (MS, CCC-SLP/L)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MICHAEL
Last Name:LEA
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MICHAEL
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP/L
Mailing Address - Street 1:9630 S SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4811
Mailing Address - Country:US
Mailing Address - Phone:918-269-6270
Mailing Address - Fax:
Practice Address - Street 1:9630 S SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4811
Practice Address - Country:US
Practice Address - Phone:918-269-6270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4008235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200471500AMedicaid