Provider Demographics
NPI:1902137631
Name:BALLARD, GRACE (MSW, LADC, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:MSW, LADC, LCSW
Other - Prefix:MRS
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:BALLARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LADC, LCSW
Mailing Address - Street 1:1232 S ATLANTA PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4311
Mailing Address - Country:US
Mailing Address - Phone:918-508-9696
Mailing Address - Fax:
Practice Address - Street 1:1232 S ATLANTA PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4311
Practice Address - Country:US
Practice Address - Phone:918-508-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK967101YA0400X
OK4548101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200398400AMedicaid