Provider Demographics
NPI:1982202438
Name:BLACKBURN, SCOTT ALEXANDER (LMSW-P)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALEXANDER
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:LMSW-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 S ASH ST
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-4628
Mailing Address - Country:US
Mailing Address - Phone:918-273-7344
Mailing Address - Fax:918-999-0111
Practice Address - Street 1:124 E 6TH ST
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056-4204
Practice Address - Country:US
Practice Address - Phone:918-604-6054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7530-P101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health