Provider Demographics
NPI:1194083600
Name:BLACC, DAEVA
Entity type:Individual
Prefix:MR
First Name:DAEVA
Middle Name:
Last Name:BLACC
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 1:3322 E 30TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-6108
Mailing Address - Country:US
Mailing Address - Phone:918-724-5680
Mailing Address - Fax:918-743-8845
Practice Address - Street 1:3322 E 30TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-6108
Practice Address - Country:US
Practice Address - Phone:918-724-5680
Practice Address - Fax:918-743-8845
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker