Provider Demographics
NPI:1386017374
Name:BALLEW, DAWN
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:BALLEW
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 1:19216 W PETTIT BAY RD
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-3010
Mailing Address - Country:US
Mailing Address - Phone:918-453-1171
Mailing Address - Fax:
Practice Address - Street 1:315 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2703
Practice Address - Country:US
Practice Address - Phone:918-453-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK49511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200606480 AMedicaid