Provider Demographics
NPI:1235728866
Name:BLACKBURN, AVERY LAUREN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:AVERY
Middle Name:LAUREN
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 MIDTOWN PL
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6347
Mailing Address - Country:US
Mailing Address - Phone:580-641-2681
Mailing Address - Fax:
Practice Address - Street 1:1620 MIDTOWN PL
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-6347
Practice Address - Country:US
Practice Address - Phone:580-641-2681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2034224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant