Provider Demographics
NPI:1235107483
Name:BROADWAY, LETTA (LCSW)
Entity type:Individual
Prefix:
First Name:LETTA
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N AIR DEPOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110
Mailing Address - Country:US
Mailing Address - Phone:405-733-9516
Mailing Address - Fax:405-733-8853
Practice Address - Street 1:801 N AIR DEPOT BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110
Practice Address - Country:US
Practice Address - Phone:405-733-9516
Practice Address - Fax:405-733-8853
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100716230BMedicaid
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