Provider Demographics
NPI:1295157774
Name:LUNDRY, BLAKE
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:
Last Name:LUNDRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 SOUTHRIDGE PLACE
Mailing Address - Street 2:#7
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3475 SOUTHRIDGE PL
Practice Address - Street 2:UNIT 7
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-7912
Practice Address - Country:US
Practice Address - Phone:918-931-1041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health