Provider Demographics
NPI:1821112855
Name:BLACK, ELIZABETH WALKER
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:WALKER
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:JANE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3824 NW 51ST PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2052
Mailing Address - Country:US
Mailing Address - Phone:405-326-6992
Mailing Address - Fax:405-632-1976
Practice Address - Street 1:4720 S SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-3210
Practice Address - Country:US
Practice Address - Phone:405-632-1900
Practice Address - Fax:405-632-1976
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator