Provider Demographics
NPI:1821592544
Name:BLASDEL, ETHAN EVERETT (MS)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:EVERETT
Last Name:BLASDEL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 E THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-2600
Mailing Address - Country:US
Mailing Address - Phone:405-372-2202
Mailing Address - Fax:405-445-3780
Practice Address - Street 1:421 E THOMAS AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-2600
Practice Address - Country:US
Practice Address - Phone:405-372-2202
Practice Address - Fax:405-445-3780
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health