Provider Demographics
NPI:1790471589
Name:BLAYLOCK, STACEY R (LCSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7127 S OLYMPIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-1856
Mailing Address - Country:US
Mailing Address - Phone:918-665-9500
Mailing Address - Fax:
Practice Address - Street 1:7127 S OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1856
Practice Address - Country:US
Practice Address - Phone:918-665-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical