Provider Demographics
NPI:1497040968
Name:GRAVES, NICHOLE D (MA, LPC, LADC/MH)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:D
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MA, LPC, LADC/MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-3644
Mailing Address - Country:US
Mailing Address - Phone:918-285-0947
Mailing Address - Fax:918-376-0170
Practice Address - Street 1:1442 E OAK ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-3644
Practice Address - Country:US
Practice Address - Phone:918-285-0947
Practice Address - Fax:918-376-0170
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1065101Y00000X
103K00000X
OK5025101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200350220CMedicaid