Provider Demographics
NPI:1841507092
Name:NORDWALL, MARY LOUISE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:NORDWALL
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 1:1131 E GARDENA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2413
Mailing Address - Country:US
Mailing Address - Phone:580-235-7593
Mailing Address - Fax:
Practice Address - Street 1:2010 BOREN BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-2050
Practice Address - Country:US
Practice Address - Phone:405-382-4507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor