Provider Demographics
NPI:1588064604
Name:BLACKWELL, VANCE WAYNE JR
Entity type:Individual
Prefix:
First Name:VANCE
Middle Name:WAYNE
Last Name:BLACKWELL
Suffix:JR
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 1:2200 SE WASHINTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006
Mailing Address - Country:US
Mailing Address - Phone:918-457-0346
Mailing Address - Fax:918-335-1119
Practice Address - Street 1:2200 SE WASHINTON BLVD.
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006
Practice Address - Country:US
Practice Address - Phone:918-457-0346
Practice Address - Fax:918-335-1119
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health