Provider Demographics
NPI:1720329188
Name:BLACKWELL, OLIVIA SHAWN (LPC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SHAWN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 HARBER RD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7918
Mailing Address - Country:US
Mailing Address - Phone:918-786-4434
Mailing Address - Fax:918-786-4435
Practice Address - Street 1:1115 HARBER RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7818
Practice Address - Country:US
Practice Address - Phone:918-786-4434
Practice Address - Fax:918-786-4435
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100750190LMedicaid