Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225C00000X | Rehabilitation Counselor |
NPI | 1003128745 |
---|---|
Provider Name | Mr. Johnny Marvell Leake SR. |
First Address | Oklahoma City, OK 73117-3024 |
Second Address | Oklahoma City, OK 73117-3024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2010 |
Last Update Date | 10/07/2010 |