Provider Demographics
NPI:1053639278
Name:BLACKWELL, DANA MELYNDA (BHRS)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:MELYNDA
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6544 NAILS CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:CADDO
Mailing Address - State:OK
Mailing Address - Zip Code:74729-2016
Mailing Address - Country:US
Mailing Address - Phone:903-816-0081
Mailing Address - Fax:
Practice Address - Street 1:6544 NAILS CROSSING RD
Practice Address - Street 2:
Practice Address - City:CADDO
Practice Address - State:OK
Practice Address - Zip Code:74729-2016
Practice Address - Country:US
Practice Address - Phone:903-816-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst