Provider Demographics
NPI:1255507372
Name:BLACKBURN, KARA LOY (MSCCC-SLP,CLT/CDT)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:LOY
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MSCCC-SLP,CLT/CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 E BOIS D ARC AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-9428
Mailing Address - Country:US
Mailing Address - Phone:405-921-3347
Mailing Address - Fax:
Practice Address - Street 1:701 W MAIN ST
Practice Address - Street 2:SUITE 10
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-4673
Practice Address - Country:US
Practice Address - Phone:405-921-3347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9320235Z00000X
OK3740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002677000Medicaid