Healthcare Provider Details

I. General information

NPI: 1992030860
Provider Name (Legal Business Name): LEORIDES R HERRON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 10/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 S YALE AVE STE 215
TULSA OK
74136-5743
US

IV. Provider business mailing address

5505 S 67TH EAST AVE
TULSA OK
74145-8527
US

V. Phone/Fax

Practice location:
  • Phone: 918-492-2554
  • Fax:
Mailing address:
  • Phone: 520-342-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: