Healthcare Provider Details

I. General information

NPI: 1225980691
Provider Name (Legal Business Name): RYANNA BLAKE OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N BIRCH AVE
BROKEN ARROW OK
74012-2694
US

IV. Provider business mailing address

1101 N BIRCH AVE
BROKEN ARROW OK
74012-2694
US

V. Phone/Fax

Practice location:
  • Phone: 539-888-6828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6272
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: