Provider Demographics
NPI:1699500363
Name:BLACK, CELIE MARIE
Entity type:Individual
Prefix:
First Name:CELIE
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W RAY FINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-5119
Mailing Address - Country:US
Mailing Address - Phone:918-427-3344
Mailing Address - Fax:
Practice Address - Street 1:109 W RAY FINE BLVD
Practice Address - Street 2:
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5119
Practice Address - Country:US
Practice Address - Phone:918-427-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator