Provider Demographics
NPI:1568683530
Name:LE BROCQ, SUZANNAH LOUISE (MPHIL)
Entity type:Individual
Prefix:MS
First Name:SUZANNAH
Middle Name:LOUISE
Last Name:LE BROCQ
Suffix:
Gender:F
Credentials:MPHIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12&12 INC.,
Mailing Address - Street 2:6333 EAST SKELLY DRIVE
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135
Mailing Address - Country:US
Mailing Address - Phone:918-664-4224
Mailing Address - Fax:
Practice Address - Street 1:12&12 INC.,
Practice Address - Street 2:6333 EAST SKELLY DRIVE
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-664-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility