Provider Demographics
NPI:1952726994
Name:BLAKE, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BLAKE
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 1:351 N AIR DEPOT BLVD STE M
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-1760
Mailing Address - Country:US
Mailing Address - Phone:405-610-3644
Mailing Address - Fax:405-610-3647
Practice Address - Street 1:5128 NW 19TH TER
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-2306
Practice Address - Country:US
Practice Address - Phone:405-886-4671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst