Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | OK |
NPI | 1003225566 |
---|---|
Provider Name | Leonard Shepherd |
First Address | Fort Smith, AR 72903-3152 |
Second Address | Tulsa, OK 74136-1077 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2014 |
Last Update Date | 18/04/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200698990 A | (05) | OK |