Provider Demographics
NPI:1114924628
Name:BLANK, ANDREA MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MICHELLE
Last Name:BLANK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15951 LITTLE AXE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73026-9088
Mailing Address - Country:US
Mailing Address - Phone:405-447-0300
Mailing Address - Fax:405-701-7914
Practice Address - Street 1:501 E 15TH ST
Practice Address - Street 2:SUITE 500A
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5043
Practice Address - Country:US
Practice Address - Phone:405-888-5299
Practice Address - Fax:405-888-5322
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical