Provider Demographics
NPI:1326726407
Name:BLACKBURN, OLIVIA LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LYNN
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 1:6812 W 480
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-7592
Mailing Address - Country:US
Mailing Address - Phone:918-693-1421
Mailing Address - Fax:
Practice Address - Street 1:5110 S YALE AVE STE 102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7438
Practice Address - Country:US
Practice Address - Phone:918-492-2386
Practice Address - Fax:918-645-8686
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2348224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant