Healthcare Provider Details

I. General information

NPI: 1851996334
Provider Name (Legal Business Name): LAURISSA FOLGER LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURISSA JOHNSON RBT

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 SW 134TH ST
MOORE OK
73170-1488
US

IV. Provider business mailing address

1900 E 15TH ST STE 800B
EDMOND OK
73013-6682
US

V. Phone/Fax

Practice location:
  • Phone: 405-265-9324
  • Fax:
Mailing address:
  • Phone: 405-455-6868
  • Fax: 405-562-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-70664
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: