Provider Demographics
NPI:1669280475
Name:BLANTON, MYCAH
Entity type:Individual
Prefix:
First Name:MYCAH
Middle Name:
Last Name:BLANTON
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 1:716 E MAIN PL
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037
Mailing Address - Country:US
Mailing Address - Phone:918-209-5190
Mailing Address - Fax:
Practice Address - Street 1:716 E MAIN PL
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037
Practice Address - Country:US
Practice Address - Phone:918-209-5190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician