Provider Demographics
NPI:1568513265
Name:BLACKWOOD, GRADY LLOYD (PHD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:LLOYD
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 NW 63RD ST
Mailing Address - Street 2:#255
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3637
Mailing Address - Country:US
Mailing Address - Phone:405-843-8026
Mailing Address - Fax:
Practice Address - Street 1:3037 NW 63RD ST
Practice Address - Street 2:#255
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3637
Practice Address - Country:US
Practice Address - Phone:405-843-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK263103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical