Provider Demographics
NPI:1427700434
Name:BALLOU, NICOLE D
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:BALLOU
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 1:19 S MAYES ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-3231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 S HARRILL AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-5317
Practice Address - Country:US
Practice Address - Phone:918-485-0242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2023-10-20
Deactivation Date:2023-03-22
Deactivation Code:
Reactivation Date:2023-10-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor