Individual
JUSTIN BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
508 E WILSON ST, VALLIANT, OK 74764-9115
(580) 743-6553
Mailing address
404 ALLEN ST, BROKEN BOW, OK 74728-3136
(580) 306-4747
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
1513
OK
Other
Enumeration date
06/07/2022
Last updated
06/07/2022
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