Basic Information
| Provider Information | |||||||||
| NPI: | 1558408989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA, BHRS CM-D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747436237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803267477 | ||||||||
| FaxNumber: | 5803266400 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747436237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803267477 | ||||||||
| FaxNumber: | 5803266400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NONE | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.