Provider Demographics
NPI:1164602033
Name:NIBLACK, KATHLEEN MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:NIBLACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 VINEYARD BLVD STE H200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-3830
Mailing Address - Country:US
Mailing Address - Phone:405-607-2995
Mailing Address - Fax:405-254-3042
Practice Address - Street 1:10400 VINEYARD BLVD STE H200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-3830
Practice Address - Country:US
Practice Address - Phone:405-516-3248
Practice Address - Fax:405-516-3249
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0101391101Y00000X
OK3442101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor