Provider Demographics
NPI:1164779708
Name:BLY, DONALD W III
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:W
Last Name:BLY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DON
Other - Middle Name:
Other - Last Name:BLY
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6200 N POST OAK RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-6428
Mailing Address - Country:US
Mailing Address - Phone:405-255-8932
Mailing Address - Fax:
Practice Address - Street 1:6200 N POST OAK RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-6428
Practice Address - Country:US
Practice Address - Phone:405-255-8932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200347170AMedicaid