MEDICARE: DR. GRADY LLOYD BLACKWOOD PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	263	OK

General Provider Information

NPI Number	:	1568513265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRADY LLOYD BLACKWOOD PH.D.

Provider Business Mailing Address
First Line	:	3037 NW 63RD ST
Second Line	:	#255
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3637
Country	:	US
Telephone Number	:	405-843-8026
Fax Number	:

Provider Business Practice Location Address
First Line	:	3037 NW 63RD ST
Second Line	:	#255
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3637
Country	:	US
Telephone Number	:	405-843-8026
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	04/16/2012

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