Healthcare Provider Details

I. General information

NPI: 1386787661
Provider Name (Legal Business Name): LISA MYERS BLACK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 24TH AVE NE
NORMAN OK
73071-7749
US

IV. Provider business mailing address

4003 24TH AVE NE
NORMAN OK
73071-7749
US

V. Phone/Fax

Practice location:
  • Phone: 214-532-9405
  • Fax: 405-573-7411
Mailing address:
  • Phone: 214-532-9405
  • Fax: 405-573-7411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1038
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: