Healthcare Provider Details

I. General information

NPI: 1083706915
Provider Name (Legal Business Name): DENNIS RAY BLACKMAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 W PERCH LN
ATOKA OK
74525-4522
US

IV. Provider business mailing address

608 W PERCH LN
ATOKA OK
74525-4522
US

V. Phone/Fax

Practice location:
  • Phone: 580-889-1067
  • Fax:
Mailing address:
  • Phone: 580-889-1067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3134
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: