Healthcare Provider Details

I. General information

NPI: 1588255194
Provider Name (Legal Business Name): MR. JOHNNY MARVELL LEAKE II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 N KELLEY AVE
OKLAHOMA CITY OK
73111-4520
US

IV. Provider business mailing address

3621 N KELLEY AVE STE. 100
OKLAHOMA CITY OK
73111-4520
US

V. Phone/Fax

Practice location:
  • Phone: 405-524-5525
  • Fax:
Mailing address:
  • Phone: 405-524-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: