Provider Demographics
NPI:1386887982
Name:SMITH, LESLIE G (LADC-MH)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:G
Last Name:SMITH
Suffix:
Gender:F
Credentials:LADC-MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 W AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-3001
Mailing Address - Country:US
Mailing Address - Phone:918-984-8900
Mailing Address - Fax:918-948-7927
Practice Address - Street 1:5272 S LEWIS AVE STE 108
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6563
Practice Address - Country:US
Practice Address - Phone:918-984-8900
Practice Address - Fax:918-948-7927
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK971101YA0400X, 101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200397730AMedicaid
OK200397730BMedicaid