Healthcare Provider Details

I. General information

NPI: 1336261817
Provider Name (Legal Business Name): TERRA JO BLACKWELL MA, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 E MAIN ST
NORMAN OK
73071-5300
US

IV. Provider business mailing address

1017 NW 6TH STREET
OKLAHOMA CITY OK
73106-7202
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-5100
  • Fax:
Mailing address:
  • Phone: 405-842-7284
  • Fax: 405-418-0324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10056
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: