Healthcare Provider Details

I. General information

NPI: 1124645833
Provider Name (Legal Business Name): MRS. ELIZABETH BLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 DARLINGTON RD NW
CALUMET OK
73014-6850
US

IV. Provider business mailing address

PO BOX 515
EL RENO OK
73036-0515
US

V. Phone/Fax

Practice location:
  • Phone: 405-401-2310
  • Fax:
Mailing address:
  • Phone: 405-401-2310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: