Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003414194 |
---|---|
Provider Name | Blake Davis |
First Address | Tulsa, OK 74137-2862 |
Second Address | Tulsa, OK 74137-2862 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2020 |
Last Update Date | 14/10/2021 |