Provider Demographics
NPI:1861580375
Name:BLACK, BRENT MATTHEW (LPC)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:MATTHEW
Last Name:BLACK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 W ELGIN ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8621
Mailing Address - Country:US
Mailing Address - Phone:918-806-1423
Mailing Address - Fax:
Practice Address - Street 1:114 N GRAND AVE
Practice Address - Street 2:SUITE 419
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-4013
Practice Address - Country:US
Practice Address - Phone:918-756-9411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3251101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional