Provider Demographics
NPI:1437320249
Name:BLANK, GARY FRED (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:FRED
Last Name:BLANK
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-5019
Mailing Address - Country:US
Mailing Address - Phone:918-756-9250
Mailing Address - Fax:918-756-9187
Practice Address - Street 1:323 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5019
Practice Address - Country:US
Practice Address - Phone:918-756-9250
Practice Address - Fax:918-756-9187
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical