Healthcare Provider Details

I. General information

NPI: 1114924628
Provider Name (Legal Business Name): ANDREA MICHELLE BLANK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E 15TH ST SUITE 500A
EDMOND OK
73013-5043
US

IV. Provider business mailing address

15951 LITTLE AXE DR
NORMAN OK
73026-9088
US

V. Phone/Fax

Practice location:
  • Phone: 405-888-5299
  • Fax: 405-888-5322
Mailing address:
  • Phone: 405-447-0300
  • Fax: 405-701-7914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2265
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: