Provider Demographics
NPI:1255987665
Name:BEASLER, NICOLE DAWN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAWN
Last Name:BEASLER
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 1:2120 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-4021
Mailing Address - Country:US
Mailing Address - Phone:405-582-2929
Mailing Address - Fax:
Practice Address - Street 1:2120 S BROADWAY
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-4021
Practice Address - Country:US
Practice Address - Phone:405-582-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor