Provider Demographics
NPI:1942403019
Name:LISA MYERS BLACK, PH.D., PLLC
Entity Type:Organization
Organization Name:LISA MYERS BLACK, PH.D., PLLC
Other - Org Name:ALTERNATIVE BEHAVIORAL HEALTH SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH SERVICE PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MYERS
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-573-4019
Mailing Address - Street 1:4003 24TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-7749
Mailing Address - Country:US
Mailing Address - Phone:405-573-4019
Mailing Address - Fax:405-573-4074
Practice Address - Street 1:4003 24TH AVE NE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-7749
Practice Address - Country:US
Practice Address - Phone:405-573-4019
Practice Address - Fax:405-573-4074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1038103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200111280AMedicaid