Healthcare Provider Details

I. General information

NPI: 1568683530
Provider Name (Legal Business Name): SUZANNAH LOUISE LE BROCQ MPHIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12&12 INC., 6333 EAST SKELLY DRIVE
TULSA OK
74135
US

IV. Provider business mailing address

12&12 INC., 6333 EAST SKELLY DRIVE
TULSA OK
74135
US

V. Phone/Fax

Practice location:
  • Phone: 918-664-4224
  • Fax:
Mailing address:
  • Phone: 918-664-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: