Provider Demographics
NPI:1306578927
Name:REDDICK, BLAKE MONET (NCSP)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:MONET
Last Name:REDDICK
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:MONET
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:402 SE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PERKINS
Mailing Address - State:OK
Mailing Address - Zip Code:74059-3404
Mailing Address - Country:US
Mailing Address - Phone:405-408-5957
Mailing Address - Fax:
Practice Address - Street 1:402 SE 3RD ST
Practice Address - Street 2:
Practice Address - City:PERKINS
Practice Address - State:OK
Practice Address - Zip Code:74059-3404
Practice Address - Country:US
Practice Address - Phone:405-408-5957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK38918103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool