Provider Demographics
NPI:1942081419
Name:BLACKWELL, BRIANA J'LISE
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:J'LISE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15201 CROWN AT LONE OAK RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2272
Mailing Address - Country:US
Mailing Address - Phone:919-525-7437
Mailing Address - Fax:
Practice Address - Street 1:15201 CROWN AT LONE OAK RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-2272
Practice Address - Country:US
Practice Address - Phone:919-525-7347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician