Healthcare Provider Details

I. General information

NPI: 1285477000
Provider Name (Legal Business Name): RENEE MAXINE BLACKWELL LPC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 E MAIN ST
NORMAN OK
73071-5300
US

IV. Provider business mailing address

17305 VITORIA DR
OKLAHOMA CITY OK
73170-6644
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12218
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: