Provider Demographics
NPI:1851802862
Name:NICHOLS-BALLIETT, MELINDA (LSW)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:
Last Name:NICHOLS-BALLIETT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:741 SCHOLL RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1571
Mailing Address - Country:US
Mailing Address - Phone:419-756-1717
Mailing Address - Fax:
Practice Address - Street 1:741 SCHOLL RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1571
Practice Address - Country:US
Practice Address - Phone:419-756-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1701170104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker