Provider Demographics
NPI:1831439751
Name:BLACET, MICHAEL A (LCSW-P)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:BLACET
Suffix:
Gender:M
Credentials:LCSW-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 W TOLEDO PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5136
Mailing Address - Country:US
Mailing Address - Phone:918-815-5425
Mailing Address - Fax:
Practice Address - Street 1:4930 S SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-5712
Practice Address - Country:US
Practice Address - Phone:918-392-4008
Practice Address - Fax:918-392-4009
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4693-P1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical