Basic Information
| Provider Information | |||||||||
| NPI: | 1568683530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LE BROCQ | ||||||||
| FirstName: | SUZANNAH | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MPHIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12&12 INC., | ||||||||
| Address2: | 6333 EAST SKELLY DRIVE | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186644224 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12&12 INC., | ||||||||
| Address2: | 6333 EAST SKELLY DRIVE | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186644224 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | OK | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.