Healthcare Provider Details

I. General information

NPI: 1205098134
Provider Name (Legal Business Name): REBECCA S BLAKE I CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA S BLAKE I CERTIFIED NURSE AID

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 S 17TH ST
CLINTON OK
73601-4236
US

IV. Provider business mailing address

408 N MO ST
THOMAS OK
73369
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-0312
  • Fax:
Mailing address:
  • Phone: 580-661-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37V350170804
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number37V350170804
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: