Basic Information
| Provider Information | |||||||||
| NPI: | 1508167578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | KELLI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186828407 | ||||||||
| FaxNumber: | 9186870976 | ||||||||
| Practice Location | |||||||||
| Address1: | 19600 E ROSS ST | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744640545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5392341000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2010 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100734050 | 05 | OK | MEDICAID |