Basic Information
| Provider Information | |||||||||
| NPI: | 1063813483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | TONY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 N AIR DEPOT BLVD STE M | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731101760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056103644 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 351 N AIR DEPOT BLVD STE M | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731101760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056103644 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2014 | ||||||||
| LastUpdateDate: | 09/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.