Healthcare Provider Details

I. General information

NPI: 1982202438
Provider Name (Legal Business Name): SCOTT ALEXANDER BLACKBURN LMSW-P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E 6TH ST
PAWHUSKA OK
74056-4204
US

IV. Provider business mailing address

325 S ASH ST
NOWATA OK
74048-4628
US

V. Phone/Fax

Practice location:
  • Phone: 918-604-6054
  • Fax:
Mailing address:
  • Phone: 918-273-7344
  • Fax: 918-999-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7530-P
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: