Provider Demographics
NPI:1235443102
Name:BLACK, BRANDY J
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:J
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 S. 9TH ST
Mailing Address - Street 2:LOT 79
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-0000
Mailing Address - Country:US
Mailing Address - Phone:405-615-0283
Mailing Address - Fax:
Practice Address - Street 1:2525 N.W. EXPRESSWAY
Practice Address - Street 2:SUITE 624-A
Practice Address - City:OKLAHOMACITY
Practice Address - State:OK
Practice Address - Zip Code:73112-0000
Practice Address - Country:US
Practice Address - Phone:405-242-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst